APPLICATION FOR EMPLOYMENT

NAME

PRESENT ADDRESS

SPECIAL QUESTIONS 

DO NOT ANSWER ANY OF THE QUESTIONS IN THIS FRAME UNLESS THE EMPLOYER HAS HIGHLIGHTED A QUESTION, THEREBY INDICATING THAT THE INFORMATION IS REQUIRED FOR A BONA FIDE OCCUPATIONAL QUALIFICATION, OR DICTATED BY NATIONAL SECURITY LAWS, OR IS NEEDED FOR OTHER LEGALLY PERMISSIBLE REASONS. 

HEIGHT

WEIGHT

*The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age. 

EMPLOYMENT DESIRED

DO NOT WRITE IN THE BOX BELOW (OFFICE USE ONLY) 

EDUCATION

*The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least , 40 but less than 70 years of age. 

FORMER EMPLOYERS  [List below last four employers, starting with most recent first.]

DATE MONTH AND YEAR 

DATE MONTH AND YEAR 

DATE MONTH AND YEAR 

DATE MONTH AND YEAR 

REFERENCES:  Give the names of three people not related to you whom you have known at least one year. 

IN CASE OF EMERGENCY NOTIFY: 

*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 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, 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 any prior notice.