Application

Application for Employment

PRE-EMPLOYMENT QUESTIONNAIRE EQUAL OPPORTUNITY EMPLOYER

Personal Information
Name*
First Middle Last
Address*
Street Address City State ZIP Code
Phone Number*
Email*
General Information
What position are you applying for?
Type
- Full Time
- Part Time
Are you seeking a permanent position?
- Yes
- No
Expected Starting Wage:
When are you available to start work?
Are you willing to work overtime?
- Yes
- No
Are you at least 18 years old?
- Yes
- No
Are you willing to do after hours service calls?
- Yes
- No
Are you a U.S. citizen?
- Yes
- No
If no, can you verify that you are authorized to work in the U.S.?
- Yes
- No
Do you have a valid driver's license?
- Yes
- No
Do you have reliable daily transportation to get to work?
- Yes
- No
What languages so you speak, read, or write fluently?
Have you ever been convicted of a felony?
- Yes
- No
(Note: Conviction will not necessarily disqualify applicant)
If so, please explain:
Employment History
Employment History
Employer name and address: Position title/duties, skills: Starting Pay: Ending Pay: Supervisor: Phone#: Start Date: End Date: Reason for leaving:
Skills and Qualifications
List any special skills, abilities, certificates, licenses, or honors that should be considered:
Education
High School
High School: Location From To Did you graduate? Degree
College
College: Location From To Did you graduate? Degree
Other
Other: Location From To Did you graduate? Degree
Military Service
Are you a military veteran?
- Yes
- No
Branch:
From
Date Format: MM slash DD slash YYYY
To
Date Format: MM slash DD slash YYYY
Rank at discharge:
Type of discharge:
Duty / specialized training:
References
List three personal references who are not related to you:
References
Name Address Phone Occupation Years Known
Certification and Acknowledgement

I certify that the information provided herein is true and correct to the best of my knowledge. I understand that, if employed, falsified statements on this Application for Employment form will be considered grounds for termination.

I understand that I may be required to supply my birth certificate or other proof of authorization to work in the United States, consent to a drug test, and/or sign a conflict of interest agreement and abide by its terms.

I authorize the company to thoroughly investigate my work experience and any other matters related to my suitability for employment. I further authorize my former employers to disclose to the company any and all information they may have concerning my previous employment. In addition, I hereby release Harper Special Services, my former employers, and all other persons from any and all claims, demands, or liabilities arising out of, or in any way related to such disclosure.

I acknowledge that, if employed, both Harper Special Services and I have the right to terminate the employment relationship at any time, with or without cause or advance notice. This employment at will relationship will remain in effect throughout my employment with Harper Special Services and may not be modified by any oral implied agreement.
Applicant's Signature and Date
Comments
This field is for validation purposes and should be left unchanged.

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Employer name and address:	Position title/duties, skills:	Starting Pay:	Ending Pay:	Supervisor:	Phone#:	Start Date:	End Date:	Reason for leaving:

Name	Address	Phone	Occupation	Years Known

Application

Application for Employment

Personal Information

General Information

Employment History

Skills and Qualifications

Education

Military Service

References

Certification and Acknowledgement