Emergency Drug Testing, LLC
2708 2nd Avenue Suite A
Lake Charles, LA 70601
Phone: (337) 479-0102
Fax: (337) 479-0182
24-hour pager (337) 421-8725
APPLICATION FOR EMPLOYMENT
PRE-EMPLOYMENT QUESTIONAIRE
EQUAL OPPURTUNITY EMPLOYER
PERSONAL INFORMATION
NAME (LAST, FIRST) |
SOCIAL SECURITY NO. | ||
PRESENT ADDRESS |
CITY |
STATE |
ZIP CODE |
PERMANENT ADDRESS |
CITY |
STATE |
ZIP CODE |
PHONE NO. ( ) |
MERGE CELLS | ||
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 THIS COMPANY BEFORE? _________YES _________NO |
WHERE? |
WHEN? | ||
EDUCATION HISTORY
NAME & LOCATION OF SCHOOL |
YEARS ATTENDED |
DID YOU GRADUATE? |
SUBJECTS STUDIED | |
GRAMMAR SCHOOL |
|
|
|
|
HIGH SCHOOL |
|
|
|
|
COLLEGE |
|
|
|
|
TRADE, BUSINESS, OR CORRESPONDENCE SCHOOL |
|
|
|
|
GENERAL INFORMATION
SUBJECTS OF SPECIAL STUDY/RESEARCH WORK OR SPECIAL TRAINING/SKILSS | |
| |
| |
NAVAL SERVICE |
|
FORMER EMPLOYERS (LIST BELOW LAST FOUR 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 |
REFERENCES GIVE BELOW THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR.
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.”
DATE_____________________________________________ SIGNATURE________________________________________________________________
(SIMPLY PROVIDE INITIALS IN THE SIGNATURE BLANK IF COMPLETING THIS APPLICATION ELECTRONICALLY)