Employment Questionnaire


PERSONAL
E-Mail		Date
Name (Last, First, M.I.)		Social Security No.
Address (Street, City, State, Zip)		Telephone No.
Position Sought		Drivers License #:
		Salary Expected
Are you a citizen of the United States?		If no, are you authorized to work in the U.S.?
Have you ever worked for this company?		If so, Date:
Have you ever been or had any convictions, pleas of guilty or no contest to a crime? If so, Date:
Nature of Crime:

EDUCATION
	Name and City	Grade Avg.	Major Study	Degree
High School
College
Other


Special training or skills (foreign languages, computer skills, machine operation, etc.)
NOTICE TO APPLICANTS: EQUAL EMPLOYMENT POLICY -- In selecting applicants we will not discriminate regarding handicap, age, sex, race, color, religion, or national origin. In the event you think you have been discriminated against because of sex, race, color, religion, or national origin, please notify the general manager of this company. You may also notify the Equal Employment Opportunity Commission, or other appropriate agency.

PREVIOUS EMPLOYMENT
List below last three employers (present and/or past) beginning with your most recent
I. Name, Address, and Phone # of Company and Type of Business	From		To		Describe in Detail the work you did	Starting Salary	Last Salary	Reason for Leaving	Name of Supervisor
	Mo.	Yr.	Mo.	Yr.


II. Name, Address, and Phone # of Company and Type of Business	From		To		Describe in Detail the work you did	Starting Salary	Last Salary	Reason for Leaving	Name of Supervisor
	Mo.	Yr.	Mo.	Yr.


III. Name, Address, and Phone # of Company and Type of Business	From		To		Describe in Detail the work you did	Starting Salary	Last Salary	Reason for Leaving	Name of Supervisor
	Mo.	Yr.	Mo.	Yr.

MILITARY SERVICE
Branch	From:	To:
Rank at Discharge:	Type of Discharge
If other than honorable, explain:

REFERENCES
Please list three professional references.
I. Full Name		Relationship
Company		Telephone No.
Address (Street, City, State, Zip)

II. Full Name		Relationship
Company		Telephone No.
Address (Street, City, State, Zip)

III. Full Name		Relationship
Company		Telephone No.
Address (Street, City, State, Zip)

I understand that my employment is at-will and my employment is terminable at the will of either my employer or me, with or without cause and with or without notice. I also understand that if employed, my employment is for no fixed or definite term and that no other employee of the company has the authority to bind the company in that regard. The information provided in this Application for Employment is true, correct and complete. If you decide to engage an investigative consumer reporting agency to report on my credit and personal history, including criminal background check, I authorize you to do so. If a report is obtained you must provide, at my request, the name and address of the agency so I may obtain from then the nature and substance of the information contained in the report. This is in compliance with the Fair Credit Reporting Act. I hereby authorized my former employers to release to Network Lubbock, Inc. any information regarding my former employment.

Date		Signature