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B & C Fire Safety Pre-Employment Questionnaire

Personal Information

First Name:(REQUIRED)
Last Name:(REQUIRED)
Email:(REQUIRED)
Social Security Number:(REQUIRED)
Present Street Address:(REQUIRED)
	City: State: Zip Code:
Permanent Street Address:
	City: State: Zip Code:
Phone Number:
Referred By:

Employment Desired

Position:
Date You Can Start:
Salary Desired:
Are You Employed:	Yes No
If so may we inquire of your present employer?	Yes No
Ever applied to B & C Fire Safety Before?	Yes No
Where?
When?

Education History

GRAMMAR SCHOOL

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

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

Subjects of special study/research work or special training/skills
u.s. military or naval service:
Rank:

Former Employers (list below last four employers, starting with the last)

Former Employer 1

Date: month and Year	from: To:
name & address of employer:
Salary:
Position:
Reason for Leaving:

Former Employer 2

Date: month and Year	from: To:
name & address of employer:
Salary:
Position:
Reason for Leaving:

Former Employer 3

Date: month and Year	from: To:
name & address of employer:
Salary:
Position:
Reason for Leaving:

Former Employer 4

Date: month and Year	from: To:
name & address of employer:
Salary:
Position:
Reason for Leaving:

References

Give Below the names of three persons not related to you. Whom you have known at least one year.

Reference #1

Name:
Address:
Business:
Years Known:

Reference #2

Name:
Address:
Business:
Years Known:

Reference #3

Name:
Address:
Business:
Years Known:

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, person 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 disability-related or medical information in a manner prohibited by the americans with disabilities Act (ADA) and other relevant federal and state laws."

Date:

Signature:
(please print your full name)

Validation

Validation question: To ensure that you are human and not a spambot, simply answer the following question in all capital letters:
Which is the hottest: FIRE or ICE ?
Please Ensure all the information provided above is accurate and truthful.