Online Pre-Employment Questionnaire
An Equal-Opportunity Employer
Date
: 11/20/2008
Personal Information:
Name:
Last:
First:
Middle:
E-mail Address:
Present Address:
Permanent Address:
Phone Number:
Are you 18 years or older?
Yes
No
Are you either a U.S. citizen or an alien authorized to work in the United States?
Yes
No
How did you hear about the position?
What days and hours are you available to work?
Desired Position:
Date you can start:
Salary Desired:
Are you employed now?
Yes
No
Have you ever been employed by this company?
Yes
No
If yes, when and where?
Former Employers
List below your last 3 employers, starting with the most recent.
Date
(Mon. / Yr.)
Name, Address & Phone of Former Employer
Salary
Position
Reason for Leaving
References
List the names of three persons, not related to you, whom you have known at least one year.
Name
Address & Phone:
Business
Years Acquainted
Have you ever been convicted of a felony?
Yes
No
If yes, please explain:
In case of emergency, please notify:
Name:
Address:
Phone #:
"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 on 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, 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."
I agree to the above statement.
Danville Services Corporation 6965 Union Park Center Suite 350 Midvale, UT 84047 Phone:(801)565-0700 Toll Free (888)417-0711
