CPG Employment Form Pre-Employment Questionnaire Equal Opportunity Employer Date of Application (required). mm/dd/yy. Your Name (required) Your Social Security Number (may be given later, in person) Your Email (required) Confirm Your Email (required) PRESENT ADDRESS Street Address City State Zip PERMANENT ADDRESS Street Address City State Zip Phone Number (301-123-1234) Secondary Phone Number (301-123-1234) Referred By EMPLOYMENT DESIRED Position Date You Can Start. mm/dd/yy. Salary Desired Are You Employed Now? YesNo If So, May We Inquire Of Your Present Employer? YesNo Ever Applied To This Company Before? YesNo Where When EDUCATION HISTORY HIGH SCHOOL Name & Location of School Years Attended Did You Graduate? YesNo Subjects Studied COLLEGE Name & Location of School Years Attended Did You Graduate? YesNo Subjects Studied TRADE, BUSINESS OR CORRESPONDENCE SCHOOL Name & Location of School Years Attended Did You Graduate? YesNo Subjects Studied GENERAL INFORMATION Subject of Special Study/Research Work Special Training Special Skills U.S. Military or Naval Service Rank FORMER EMPLOYERS (List Below Last Four Employers, Starting with Last One First) EMPLOYER ONE (Most Recent) Employed From (Date - Month & Year) Employed To (Date - Month & Year) Name & Address of Employer Salary Position Reason for Leaving EMPLOYER TWO Employed From (Date - Month & Year) Employed To (Date - Month & Year) Name & Address of Employer Salary Position Reason for Leaving EMPLOYER THREE Employed From (Date - Month & Year) Employed To (Date - Month & Year) Name & Address of Employer Salary Position Reason for Leaving EMPLOYER FOUR Employed From (Date - Month & Year) Employed To (Date - Month & Year) 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 ONE Name Address Business Years Known REFERENCE TWO Name Address Business Years Known REFERENCE THREE 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, 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 disability-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. Signature Full Name (required) Signature Date (required). mm/dd/yy. Certify Signature (required) Certified ANTI-SPAM Please re-type the letters below. (Not case sensitive).