Pre-Employment Questionnaire, Equal Opportunity Employer


Full Name: Social Security No.:
Present Address: City: State: Zip Code:
Permanent Address: City: State: Zip Code:
Phone No.: Secondary Phone No.: Referred By


Employment Desired

Position: Date You Can Start: Salary Desired:
Are You Employed Now?: If So, May We Inquire Your Present Employer?:
Ever Applied To This Company Before?: Where: When:

Education History


High School

Name & Location of School: Years Attended: Did You Graduate: Subjects Studied:


College

Name & Location of School: Years Attended: Did You Graduate: Subjects Studied:


Trade, Business, Or Correspondence School

Name & Location of School: Years Attended: Did You Graduate: Subjects Studied:

General Information

Subject of Special Study / Research Work
Special Training:
Special Skills:
U.S. Military Or Naval Service And Rank:

Former Employer

Please list four (4) former employers, starting with your last one first.

Starting Date Employed/Ending Date: Name & Address of Employer: Salary: Position: Reason For Leaving:
Starting Date Employed/Ending Date: Name & Address of Employer: Salary: Position: Reason For Leaving:
Starting Date Employed/Ending Date: Name & Address of Employer: Salary: Position: Reason For Leaving:
Starting Date Employed/Ending Date: Name & Address of Employer: Salary: Position: Reason For Leaving:

References

List the names of three persons not related to you, whom you have known at least one year.

Name: Address: Business: Years Known:
Name: Address: Business: Years Known:
Name: Address: Business: Years Known:

Additional Application Questionnaire

1. Have you ever been convicted of a felony?YesNo
If Yes, please describe:
2. Have you been convicted of a misdemeanor withing the last 5 years? YesNo
If Yes, please describe:
3. Do you understand you will be requred to take a pre-employment drug test? YesNo
4. Do you agree to pay $35 for the pre-employment drug test? YesNo
5. Do you understand a background check will be conducted by our office? YesNo
6. Is Jubilee Donuts allowed to contact previous employers?YesNo
7. Are you able to lift 50lbs? YesNo
8. Are you at least 18 years of age? YesNo
9. Are you able to work weekends? YesNo
10. Are you able to work extra days? YesNo
11. Are you able to work holidays? YesNo
12. Are you able to work multiple locations? YesNo
13. Are you able to work different shifts? YesNo
14. Are there any medical reasons that will affect your job? YesNo
15. Have you smoked or used any form of tobacco in the last 90 days? YesNo
16. Will you refrain from all use of drugs and tobacco during your employment? YesNo
17. Do you agree to cover or remove all visible tattoos or piercings while on duty? YesNo
18. Any special shift restrictions? YesNo
If Yes, please explain:
19. Shift Availability : Check all shifts you are interested in. AM Shift (start time 4:30am-6:30am)PM Shift (start time 11:15-11:45am)Production Shift (start time 5pm-6pm)Driver Shift (start time 2am)
20. Day Availability. Check all days you are able to work below.SundayMondayTuesdayWednesdayThursdayFridaySaturday
21. Check which you are interested in. (Check both if both apply.) Part TimeFull Time

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 company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

This waiver does not permit the release or use of diability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.

I understand that a consumer credit report or criminal records check may be necessary prior to my employment. If such reports are required, i understand that, in compliance with federal law, the company will provide me with a written notice regarding the use of these reports and will also obtain a separate written authorization from me to consent to these reports. I also understand that a poor credit history or conviction will not automatically result in disqualification from employment.*

In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire.

By clicking the "Send" button below I understand the terms written above.