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Kansas(Pre-Employment questionnaire) We are an equal opportunity employer. All applicants are considered, without regard to race, color, religion, sex, national origin, age, marital or veteran staus, physical or mental disability, or any other legally protected status.
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Date of Application
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Full Name
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E-Mail Address
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Present Address
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Permanent Address
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Home Phone Number
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Cell Number
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Position Desired
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Preferred Work Schedule
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Date You Can Start
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Are you willing to work overtime if requested?
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No
Yes
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Salary Range Desired
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Are you employed now?
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No
Yes
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Have you ever been employed by this company before?
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No
Yes
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If yes, give date
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Are you 18 years of age or older?
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No (proof may be required if employed)
Yes
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How were you referred to us?
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Are you legally able to be employed in this country?
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No (proof may be required if employed)
Yes
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Do you have a current drivers license?
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Commercial
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No
Yes
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(Do not answer this question unless you have been informed of the requirements of this position.)
Are you capable of performing the essential functions of this position as they have been outlined for you?
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No
Yes
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If not, what function(s) can you NOT perform and what accommodation(s) would be required in order for you to perform these function(s)?
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EDUCATION
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High School
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Years Completed & Year Graduated
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College
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Years Completed & Year Graduated & Name of Degree/Diploma
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Trade or Business School
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Years Completed & Year Graduated & Name of Degree/Diploma
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List any special honors, certificates, awards or training you have received
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Note any additional information that may be helpful to us in considering your application
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What has motivated you to submit an application with Stutzmans Greenhouse?
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In what way would Stutzmans benefit by having you as an employee?
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PERSONAL REFERENCES - List three persons who are NOT RELATED to you
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Please list their Name, Address, Phone Number, Business and Years Acquainted
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EMPLOYMENT EXPERIENCE - Start with your present or last job.
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#1 Dates Employed - From & To, Employer, Supervisor, Address & Phone Number
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Position - Work Performed
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Salary - Starting & Ending
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Reason For Leaving
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May we contact
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No
Yes
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#2 Dates Employed - From & To, Employer, Supervisor, Address & Phone Number
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Position - Work Performed
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Salary Starting & Ending
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Reason for Leaving
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May we contact?
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No
Yes
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#3 Dates Employed From & To, Employer, Supervisor, Address & Phone Number
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Position - Work Performed
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Salary Starting & Ending
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Reason for Leaving
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May we Contact?
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No
Yes
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Have you been convicted of a felony or misdemeanor?
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No
Yes
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(Convictions are not a bar to employment in all cases. Each situation is evaluated individually.)
If yes, Please describe:
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"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 or interview may be grounds for dismissal.
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I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous employment and any pertinent information that they may have, personal or otherwise, and release all parties from all liability from any damage that may result from furnishing same to you.
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I understand and agree that, if hired, my employment will be "at will", without any definite period of time, and may be terminated at any time, with or without cause and with or without prior notice, regarless of the date of payment of my wages or salary.
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I understand that as a condition of employment, I may be required to undergo a medical examination and substance test.
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Date
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Signature
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800-279-4505