White Eagle Conference Center PO Box 679 Hamilton, NY 13346
Application for Employment (Pre-Employment Questionnaire) (An Equal Opportunity Employer)
Personal Information	Date _______________________
Name: _________________________________________________	Social Security#: _____________
First Middle Last
Present Address: ____________________________________________________________
Street City State Zip
Permanent Address: __________________________________________________________
Street City State Zip
Telephone Number: ____________ Are you 18 years or older? (Circle One) Yes No
Are you prevented from lawfully becoming employed in this country because of VISA or Immigration Status?
Yes ______________________________ No ______________________________
Employment Desired
Position: ________________ Date you can start: ________ Salary Desired: ___________
Are you employed now? Yes or No If so, may we inquire of your present employer? Yes or No
Ever applied to this company before? Where? ___________ When? ____________
Referred by: ________________________________________________________________
Education Name & Location of School *No. of Years Attended *Did you Graduate Subjects Studied Grammar School         High School         College         Trade, Business or Correspondence School
General
Subjects of Special Study or Research Work: _______________________________________________
_____________________________________________________________________________________
Special Skills: _________________________________________________________________________
Activities: (Civic, Athletic, Etc.) ___________________________________________________________
Exclude Organizations, The Name of which indicates the Race, Creed, Sex, Age, Martial Status, Color or Nation of Origin of its members.
U.S. Military or Naval Service ________________ Rank ____ Present Membership in National Guard or Reserves ______________
*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.
Former Employers (List Below Last Three Employers, Starting with Last One First)
Date Month and Year Name & Address of Employer Salary Position Reason for Leaving From         To From         To From         To From         To
Which of these jobs did you like the best? __________________________________________________
What did you like most about this job? _____________________________________________________
References: Give the names of 3 persons NOT related to you, whom you have known at least one year.
Name Address Business Years Acquainted 1       2       3
The following statement applies in Maryland and Massachusetts. (Fill in name of state) It is unlawful in he state of ________________ to require or administer a lie detector test as a condition of employment or continued employment, an employer who violates this law shall be subject to criminal penalties and civil liability.
______________________________
Signature of Applicant
"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 anytime. 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 it's 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 ____________________ Signature ___________________________________
DO NOT WRITE BELOW THIS LINE
Interviewed By: Date:
Remarks:
Neatness Ability
Hired: Yes or No Position Dept
Salary/Wage Date Reporting to Work
Approved:
Employment Manager Department Head General Manager
This form has been designed to strictly compy with State and Federal fair employment practice laws prohibiting employment discrimination. This Application for Employment is sold for general use throughout the United States. TOPS assumes no responsibility for the inclusion in said form of any questions which, when asked by the Employer of the Job Applicant, may violate State and/or Federal Law.