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PRE-EMPLOYMENT QUESTIONAIRE – AN EQUAL OPPORTUNITY EMPLOYER

PERSONAL INFORMATION

Today's Date

Name *

First

Middle

Last

Present Address *

Address Line 1

Address Line 2

City

State

Zip Code

Permanent Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Are you prevented from lawfully becoming employed in this country because of visa or immigration status? *

Yes
No

Are you 18 years of age or older? *

Yes
No

EMPLOYMENT DESIRED

Position Sought

Fabricator
Metal Finisher
Maintenance
Other

Date you can start

Ever applied here before?

Yes
No

EDUCATION

GRAMMAR SCHOOL NAME & TOWN

NUMBER OF YEARS ATTENDED

DID YOU GRADUATE?

Yes
No

SUBJECTS STUDIED

HIGH SCHOOL NAME & TOWN

NUMBER OF YEARS ATTENDED

DID YOU GRADUATE?

Yes
No

SUBJECTS STUDIED

COLLEGE NAME & TOWN

NUMBER OF YEARS ATTENDED

DID YOU GRADUATE?

Yes
No

SUBJECTS STUDIED

TRADE SCHOOL NAME & TOWN

NOTE: This form has been revised to comply with the provisions of the Americans with Disabilities Act and the final regulations and interpretive guidance promulgated by the EEOC on July 26, 1991.

NUMBER OF YEARS ATTENDED

DID YOU GRADUATE?

Yes
No

SUBJECTS STUDIED

SUBJECT(S) OF SPECIAL STUDY

SPECIAL SKILLS OR TRAINING

ACTIVITIES (CIVIC, ATHLETIC, ETC.)

(EXCLUDE ORGANIZATIONS, THE NAME OF WHICH INDICATES THE RACE, CREED, SEX, MARITAL STATUS, COLOR OR NATION OF ORIGIN OF ITS MEMBERS.)

VALID PA DRIVER'S LICENSE *

Yes
No

SERVED IN U.S. ARMED FORCES

Yes
No

HIGHEST PAY GRADE ATTAINED

PRESENT MEMBER IN NATIONAL GUARD OR RESERVES?

Yes
No

FORMER EMPLOYERS

LIST LAST FOUR EMPLOYERS STARTING WITH MOST RECENT FIRST

1. EMPLOYER NAME & ADDRESS

ANNUAL SALARY

JOB TITLE

END DATE

START DATE

REASON FOR LEAVING

CONTACT NAME & PHONE

2. EMPLOYER NAME & ADDRESS

ANNUAL SALARY

JOB TITLE

END DATE

START DATE

REASON FOR LEAVING

CONTACT NAME & PHONE

3. EMPLOYER NAME & ADDRESS

ANNUAL SALARY

JOB TITLE

END DATE

START DATE

REASON FOR LEAVING

CONTACT NAME & PHONE

4. EMPLOYER NAME & ADDRESS

ANNUAL SALARY

JOB TITLE

END DATE

START DATE

REASON FOR LEAVING

CONTACT NAME & PHONE

WHICH OF THESE JOBS DID YOU LIKE BEST?

WHAT DID YOU LIKE MOST ABOUT THIS JOB?

REFERENCES

LIST THE NAMES OF THREE PERSONS NOT RELATED TO YOU THAT YOU HAVE KNOWN AT LEAST ONE YEAR

1. NAME

ADDRESS

PHONE NUMBER

YEARS KNOWN

2. NAME

ADDRESS

PHONE NUMBER

YEARS KNOWN

3. NAME

ADDRESS

PHONE NUMBER

YEARS KNOWN

Are you legally permitted to work in the United States?

Yes
No

Are you more than 18 years of age?

Yes
No

Have you ever been convicted of a crime other than misdemeanor?

Yes
No

If yes, explain below.

Explanation

May we contact your present employer for references?

Yes
No

May we contact your previous employers for references?

Yes
No

IS THERE ANYTHING ELSE YOU WOULD LIKE TO TELL US ABOUT YOURSELF?

(OPTIONAL) If you have a resume you may upload it here

Drag & Drop Files, Choose Files to Upload

(OPTIONAL) If you have a cover letter, you may upload it here

Drag & Drop Files, Choose Files to Upload

(OPTIONAL) Any additional Information may be entered here

Contact

Keystone Avenue
PO Box 251
Schuylkill Haven, PA 17972
570.385.3460
570.385.5261
wlm@ebingeriron.com

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