Document Text
--- Document: Borough Employment Application Document ---
ROUGH OF CARTERE
NEW JEE
APPLICATION FOR EMPLOYMENT
(PRE-EMPLOYMENT QUESTIONNAIRE) (AN EQUAL OPPORTUNITY EMPLOYER)
PERSONAL INFORMATION
DATE
NAME
SOCIAL SECURITY
NUMBER
LAST
FIRST
MIDDLE
PRESENT ADDRESS
STREET
CITY
STATE
ZIP
PERMANENT ADDRESS
STREET
CITY
STATE
ZIP
PHONE NO.
ARE YOU 18 YEARS OR OLDER? Yes No
ARE YOU PREVENTED FROM LAWFULLY BECOMING EMPLOYED
IN THIS COUNTRY BECAUSE OF VISA OR IMMIGRATION STATUS?
Yes
No
EMPLOYMENT DESIRED
POSITION
ARE YOU EMPLOYED NOW?
EVER APPLIED TO THIS COMPANY BEFORE?
REFERRED BY
EDUCATION
GRAMMAR SCHOOL
HIGH SCHOOL
DATE YOU
CAN START
SALARY
DESIRED
IF SO MAY WE INQUIRE
OF YOUR PRESENT EMPLOYER?
WHERE?
NAME AND LOCATION OF SCHOOL
COLLEGE
TRADE BUSINESS OR
CORRESPONDENCE
SCHOOL
GENERAL
SUBJECTS OF SPECIAL STUDY OR RESEARCH WORK
WHEN?
*NO OF
*DID YOU
YEARS GRADUATE?
ATTENDED
LAST
SUBJECTS STUDIED
SPECIAL SKILLS
ACTIVITIES: (CIVIC, ATHLETIC, ETC.)
EXCLUDE ORGANIZATIONS, THE NAME OF WHICH INDICATE THE RACE, CREED, SEX, AGE, MARITAL STATUS, COLOR, OR NATION OF ORIGIN OF ITS MEMBERS
U.S. MILITARY OR
NAVAL SERVICE
RANK
FIRST
PRESENT MEMBERSHIP IN
NATIONAL GUARD OR RESERVES
(CONTINUED ON OTHER SIDE)
MIDDLE
FORMER EMPLOYERS (LIST BELOW LAST THREE EMPLOYERS, STARTING WITH THE LAST ONE FIRST)
DATE
MONTH AND YEAR
NAME AND ADDRESS OF EMPLOYER
SALARY
FROM
TO
FROM
TO
FROM
TO
FROM
TO
WHICH OF THESE JOBS DID YOU LIKE BEST?
WHAT DID YOU LIKE MOST ABOUT THIS JOB?
POSITION
REASON FOR LEAVING
REFERENCES: GIVE THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR:
1.
2.
3.
NAME
ADDRESS
BUSINESS
YEARS
ACQUAINTED
TO REQUIRE OR ADMINISTER A LIE DETECTOR TEST AS A
THE FOLLOWING STATEMENT APPLIES IN: MARYLAND & MASSACHUSETTS (NAME OF STATE)
IT IS UNLAWFUL IN THE STATE OF
CONDITION OF EMPLOYMENT OR CONTINUED EMPLOYMENT. AN EMPLOYER WHO VIOLATES THIS LAW SHALL BE SUBJECT TO
CRIMINAL PENALTIES AND CIVIL LIABILITY,
IN CASE OF
EMERGENCY NOTIFY
Signature of Applicant
ADDRESS
NAME
PHONE NO.
*I CERTIFY THAT ALL THE INFORMATION SUBMITTED BY ME ON THIS APPLICATION IS TRUE AND COMPLETE, AND 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 CARTERET ADMINISTRATION'S RULES AND REGULATIONS, AND I
AGREE THAT MY EMPLOYMENT AND COMPENSATION CAN BE TERMINATED WITH OR WITHOUT CASE, 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 THE MAYOR, AND THEN ONLY WHEN IN WRITING AND SIGNED BY THE MAYOR, HAS ANY AUTHORITY
TO ENTER INTO AN AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIC PERIOD OF TIME, OR TO MAKE ANY AGREEMENT CONTRARY TO THE
FOREGOING.
DATE
INTERVIEWED BY
REMARKS
SIGNATURE
DO NOT WRITE BELOW THIS LINE
DATE
NEATNESS
ABILITY
HIRED:
Yes
No
POSITION
DEPT.
SALARY/WAGE
DATE REPORTING TO WORK
APPROVED: 1.
2.
3.
MAYOR
DEPT. HEAD
This form has been designed to strictly comply with State and Federal fair employment practice laws prohibiting employment discrimination
COUNCILMAN
I hereby certify that the foregoing statements made by me are true. I am aware that if any of the
foregoing statements made by me are willfully false, I am subject to punishment.
Print name:
Date
Be advised that pursuant to N.J.S.A. 2C:28-3 one may be subject to incarceration and/or a
fine for making or submitting a written false statement hereon.