Application for Employment Pre-Employment Questionnaire Equal Opportunity Employer
Social Security #:
Referred by: Date you can start:
Hrs / Week Desired:
Available Work Schedule – Check desired shift times and days M
5AM – 11AM 10AM – 4PM 4PM – 10PM Are you currently employed? Yes ( ) No ( ) Do you have regular, dependable transportation to work? Yes ( ) No ( ) Do you understand that this business is under 24-hour surveillance by camera? Yes ( ) No ( ) Education History: High School:
Former Employers Dates:
Name of Employer:
Reason for leaving:
How do you know this person?
Authorization: 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 and employers 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 the Meadows from all liability for any damages that may result from utilization of such information. This waiver does not permit the release of use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and any other relevant federal or state laws.