Job Application Pre-Employment Questionnaire - An Equal Opportunity Employer Step 1 of 4 - Personal Information 0% Personal InformationName* Prefix First Last Suffix Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Phone #*Are you 18 years or older?*YesNoEmployment DesiredPosition Applying For*Date you can start* Salary desired*Are you employed now?*YesNoIf so, may we inquire of your present employer?YesNoHave you ever applied to this company before?*YesNoIf so, where?When?How did you hear about this job opportunity?EducationGrammar School*Name and location of school, # of years attended, did you graduate?High School*Name and location of school, # of years attended, did you graduate?College*Name and location of school, # of years attended, subjects studied, did you graduate? type of degree earnedTrade, Business, or Correspondence School*Name and location of school, # of years attended, subjects studied, did you graduate? type of degree earned GeneralSubjects of Special Study or Research WorkSpecial SkillsActivities (Civic, Athletic, Social, etc.)Exclude organizations, the name of which indicates the race, creed, sex, age, marital status, color or nation of its members.U.S. Military ServicePresent membership in National Guard or Reserves?YesNo Former EmployersPlease list your last three employers, starting with the last one first:*Include Name and Address of Employer, Dates of employment, Position, Salary, and Reason for leavingWhich of these jobs did you like best?*What did you like most about this job?*ReferencesGive the names of three persons not related to you, whom you have known at least one year.Reference 1Name, Address, Business, Years AcquaintedReference 2Name, Address, Business, Years AcquaintedReference 3Name, Address, Business, Years AcquaintedIn Case of Emergency, Notify:Name* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone* Confirmation of Accuracy*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 make any agreement contrary to the foregoing.*I agree with the above statement (digital signature)I disagree with the above statementAuthorization of Background CheckAuthorization for Verification of Information Provided for Potential EmploymentThe information given by me is certified to be truthful and complete. The Dutch Group may verify all information enclosed in the documents presented for completion. The Dutch Group will rely upon my statements in considering my application. I agree that the information is true and complete to the best of my knowledge. If a position is offered and/or accepted and this information is found to be a misrepresentation, The Dutch Group is relieved of all commitments, financial or otherwise, pertinent to employment. I understand that I would be subject to discharge and/or denial of benefits under the worker's compensation act. If employed on a full or part-time basis, I agree to accept each assignment as scheduled individually, and that no prior assignment shall be deemed to establish a regular or permanent schedule. I understand that this application will be considered active for thirty (30) days, after which time I must re-apply in order to maintain an active application for employment. For the purpose of enabling The Dutch Group, and/or its representatives to conduct a background investigation to qualify me for employment, I authorize The Dutch Group to: 1. Develop information regarding my work habits, skills, and general character from employers, listed or developed references. 2. Obtain information from law enforcement and military authorities concerning my conduct, including traffic violations. 3. Obtain information from educational institutions concerning my educational record, conduct, skills, habits, or character. 4. Conduct pre-employment test and background check as pertinent to employment. 5. Obtain motor vehicle driving record as pertinent to employment. 6. Conduct a pre-employment drug screen and understand that positive results, refusal to be tested or any attempt to affect the test results or test sample will result in withdrawal of my application for employment, withdrawal of any provisional employment offer I have received from The Dutch Group, or termination of employment, depending on when results are received. I give permission for my drug screen results to be released to the Director of Human Resources. The Dutch Group is an Equal Employment Opportunity Employer, and does not discriminate in our hiring or employment practices. All qualified applicants will receive consideration without regard to race, color, creed, religion, national origin, age disability, sex, or any other characteristic protected by State or Federal law.I have read and fully understand the information written pertaining to potential employment with The Dutch Group.*Agree (digital signature)DisagreePhoneThis field is for validation purposes and should be left unchanged.
