Exline Inc. Application for Employment

(Pre-Employment Questionnaire) (An Equal Opportunity Employer)

*Required Field

PERSONAL INFORMATION	*Date:

NAME

*Last:	*First:	*MI:

CONTACT INFO	ADDRESS

*Phone:	*Street:
Cell:	*City:
E-Mail:	*State:
	*Zip:

*	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
*	Have you failed or refused a Department of Transportation drug or alcohol pre-employment test within the past three years from a potential employer who did not hire you?	Yes No
*	Have you ever been convicted of a crime, other than a traffic violation?	Yes No
	If yes, please provide details
*	Social Security number or Visa number & type


EMPLOYMENT DESIRED

*	Position:
*	Date you can start:
*	Pay Range Desired:
*	Are you willing to travel?	Yes No
*	Are you employed now?	Yes No
*	If so, may we inquire of your present employer?	Yes No
*	Have you applied to this company before?	Yes No
	When:
	Referred By:


FORMER EMPLOYERS (List below your last four employers, starting with the last one first).

Employer 1
*Name of Employer:	*Position:
Address of Employer:	*Salary:
		Date (Month and Year)
*Reason for Leaving:	*From:
Phone:	*To:

Employer 2
*Name of Employer:	*Position:
Address of Employer:	*Salary:
		Date (Month and Year)
*Reason for Leaving:	*From:
Phone:	*To:

Employer 3
*Name of Employer:	*Position:
Address of Employer:	*Salary:
		Date (Month and Year)
*Reason for Leaving:	*From:
Phone:	*To:

Employer 4
Name of Employer:	Position:
Address of Employer:	Salary:
		Date (Month and Year)
Reason for Leaving:	From:
Phone:	To:


EDUCATION

	Name and Location of School	No. of Years Attended	Did You Graduate?	Subjects Studied
High School:			Yes No
College:			Yes No
Trade, Business, or Correspondence School:			Yes No

GENERAL

Subjects of Special Study or Research Work:
Special Skills:
U.S. Military Services:
Rank:
Present Membership in National Guard or Reserves:
Service Organizations:


REFERENCES: Give the names of three persons not related to you, whom you have known at least one year.
	Name	Phone and Address	Business	Years Acquainted
*1.
*2.
3.


Attach Resume (Optional)

In case of emergency notify:
*Name:	*Address:	*Phone:

Our hiring policy is simple: WE FOLLOW THE LAW!

This company hires lawful workers only - U.S. citizens or nationals and non-citizens with valid work authorization – without discrimination.

Federal immigration law requires all employers to verify both the identity and employment eligibility of all persons hired to work in the United States.

In its efforts to meet the law’s requirements, this company is participating in the Basic Pilot program established by the Department of Homeland Security and the Social Security Administration (SSA) to aid employers in verifying the employment eligibility of all newly-hired employees. Our participation in the pilot program does not exempt us from the obligation to complete a Form I-9 for everyone we hire.

For additional information on the verification program contact the:

Department of Homeland Security
USCIS/SAVE Program
111 Massachusetts Avenue, 2nd floor
Washington, DC 20001
Phone (888) 464-4218

INVITATION TO IDENTIFY FOR AFFIRMATIVE ACTION PURPOSES

Exline, Inc. is an equal opportunity employer and does not discriminate in hiring or employment on the basis of race, color, religion, sex, national origin, age, disability, or any other basis prohibited by federal, state, or local law. No question on this form in intended to secure information to be used for such discrimination. Exline, Inc. is required by federal regulations to report information as requested below. Your contribution of this information is completely voluntary and in no way affects the decision regarding your employment opportunity. The information you provide is strictly confidential and will be maintained separate from your application form.

Applicant Name: Date:

Position Applied For:

PLEASE CHECK ONE: Male Female

INDICATE THE APPROPRIATE RACE/ETHNIC GROUP:

"I certify that all the information submitted by me on this application is true and complete, and I 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 company’s rules and regulations; and I agree that my employment and compensation can be terminated, with or without cause, 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 its President, and then only when in writing and signed by the President, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing."


Have you read USCIS/SAVE information? Español English Yes No

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