2100 S. Yellow Springs Street
Springfield, Ohio 45506
Phone: 937-325-5561
Fax: 937-325-1957

Employment Application (Pre-Employment Questionnaire)
(Equal Opportunity Employer)

Last Name:

First Name:

Middle:

Social Security #:

Street:

City:

State

Zip

Phone:

Email:

Are you 18 years or older?
no yes

Are you either a U.S. citizen or an alien
authorized to work in the United States?
no yes

Position

Salary desired

Are you employed now? no yes

Have you ever applied to this company before?
no yes

	Name and Location of School	Number of years attended	Did you graduate?	Subjects studied
High School
College

Job related skills (typing, driver's license, etc...):

(List below last three employers, starting with last one first)

Date
Month and Year

Employers Name and Address

Salary

Position

Reason For Leaving

From:
To:

From:
To:

From:
To:

(Give the name of two (2) persons familiar with your work ability, not related to you, whom you have known at least one year)

Name	Address	Phone	Business	Years Aquainted

How many work or school days have you missed
for any reason in the last twenty-four months?
days

What shifts are you willing to work?

Are you willing to work overtime?
no yes

Have you ever been convicted of a felony?
no yes

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

I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, including police records, and release all parties from all liability for any damage that may result from furnishing same to you.

I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without prior notice.

After the employment offer, I consent to a pre-placement physical examination which includes drug testing as a condition of employment."

Employment Application (Pre-Employment Questionnaire)(Equal Opportunity Employer)

Employment Application (Pre-Employment Questionnaire)
(Equal Opportunity Employer)