Pre-Employment Questionnaire

Personal Information

Date

Last name

First

M.I.

Address

City State Zip

How long?

Home phone

Best time to call

E-mail address

Alternate phone

(This is my ) Best time to call

Are you 18 or more years old?
Yes No

Are you prevented from lawfully becoming employed in this country because of visa or immigration status?
Yes No

Paste the text of your resume here:

Former Employers (Last three employers, starting with last one first)

Employer 1

Dates Employed

Address

City State Zip

Salary

Position

Reason for leaving

Employer 2

Dates Employed

Address

City State Zip

Salary

Position

Reason for leaving

Employer 3

Dates Employed

Address

City State Zip

Salary

Position

Reason for leaving

I am applying for employment as a result of: Seeing your advertisement in:

Seeing your listing on this web site:

Referred by:

Other:

In case of emergency notify

Relationship

Address

City State Zip

Phone

I certify that all the information submitted by me on this application is true and complete, and I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected and, if I am employed, my employment may be terminated at any time. In consideration of my employment, I agree to conform to the company's rules and regulations, and I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company's option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice, at any time by the company. I understand that no company representative, other than its president, and then only when in writing and signed by the president, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing.

Date

Initials

Notice: You will be required to pass a pre-employment physical and drug-screening test before employment may begin.

Come to the Village to talk with us about full-time or part-time positions. Come to 34 North Main Street Jacobus, PA. (I83 exit 14 West) , or fax resume to (717) 428-2890 or email us: hr@smithvillage.com.