Application for Employment

PRE-EMPLOYMENT QUESTIONNAIRE.
EQUAL OPPORTUNIT EMPLOYER.
Asterisk indicates Required Field

Personal Information

  • NAME (LAST NAME FIRST)
    *
  • EMAIL
    *
  • PRESENT ADDRESS
  • PRESENT CITY
  • PRESENT STATE
  • PRESENT ZIP CODE
  • PERMANENT ADDRESS
  • PERMANENT CITY
  • PERMANENT STATE
  • PERMANENT ZIP CODE
  • PHONE NO.
  • SECONDARY PHONE NO.
  • REFERRED BY

Employment Desired

  • POSITION
  • DATE YOU CAN START
  • SALARY DESIRED
  • ARE YOU EMPLOYED NOW?
    Yes No
  • IF SO, MAY WE INQUIRE OF YOUR PRESENT EMPLOYER?
    Yes No
  • EVER APLLIED TO THIS COMPANY BEFORE?
    Yes No
  • IF SO, WHERE?
  • IF SO, WHEN?

Education History

  • HIGH SCHOOL

    • NAME & LOCATION OF SCHOOL
    • YEARS ATTENDED
    • DID YOU GRADUATE
    • SUBJECTS STUDIED

  • COLLEGE

    • NAME & LOCATION OF SCHOOL
    • YEARS ATTENDED
    • DID YOU GRADUATE
    • SUBJECTS STUDIED

  • TRADE, BUSINESS, OR CORRESPONDENCE SCHOOL

    • NAME & LOCATION OF SCHOOL
    • YEARS ATTENDED
    • DID YOU GRADUATE
    • SUBJECTS STUDIED

General Information

  • SUBJECT OF SPECIAL STUDY/RESEARCH STUDY
  • SPECIAL TRAINING
  • SPECIAL SKILLS
  • U.S. MILITARY OR NAVAL SERVICE
  • RANK

Former Employers

LIST BELOW LAST FOUR EMPLOYERS, STARTING WITH THE LAST
 

  • EMPLOYER 4

    • START DATE (DATE, MONTH & YEAR)
    • END DATE (DATE, MONTH & YEAR)
    • NAME & ADDRESS OF EMPLOYER
    • SALARY
    • POSITION
    • REASON FOR LEAVING

  • EMPLOYER 3

    • START DATE (DATE, MONTH & YEAR)
    • END DATE (DATE, MONTH & YEAR)
    • NAME & ADDRESS OF EMPLOYER
    • SALARY
    • POSITION
    • REASON FOR LEAVING

  • EMPLOYER 2

    • START DATE (DATE, MONTH & YEAR)
    • END DATE (DATE, MONTH & YEAR)
    • NAME & ADDRESS OF EMPLOYER
    • SALARY
    • POSITION
    • REASON FOR LEAVING

  • EMPLOYER 1

    • START DATE (DATE, MONTH & YEAR)
    • END DATE (DATE, MONTH & YEAR)
    • NAME & ADDRESS OF EMPLOYER
    • SALARY
    • POSITION
    • REASON FOR LEAVING

References

GIVE BELOW THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOW AT LEAST ONE YEAR.
 

  • REFERENCE 1

    • NAME
    • ADDRESS
    • BUSINESS
    • YEARS KNOW

  • REFERENCE 2

    • NAME
    • ADDRESS
    • BUSINESS
    • YEARS KNOW

  • REFERENCE 3

    • NAME
    • ADDRESS
    • BUSINESS
    • YEARS KNOW

Authorization

"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing unless it is in writing and signed by an authorized company representative.

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.

I understand that a consumer credit report or criminal records check may be necessary prior to my employment. Id such reports are required, I understand that, in compliance with federal law, the company will provide me with a written notice regarding the use of these reports and will also obtain a separate written authorization from me to consent to these reports. I also understand that a poor credit history or conviction will not automatically result in disqualification from employment."


In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire.
  • DATE
  • SIGNATURE

Do Not Write Below This Line

  • REMARKS
  • NEATNESS
  • CHARACTER
  • PERSONALITY
  • ABILITY
  • HIRED
  • FOR DEPT.
  • POSITION
  • WILL REPORT
  • SALARY WAGES

APPROVED:

  • EMPLOYMENT MANAGER
  • DEPARTMENT HEAD
  • GENERAL MANAGER
This application for employment is sold only for general use throughout the United States. TOPS assumes no responsibility and hereby disclaims any liability for the inclusion in this form of any questions or requests for information upon which a violation of local, state, and/or federal law may be based. It is the user's responsibility to ensure that this form's use complies with applicable laws, which change from time to time.