Title: Employment Interview Checklist
Author: Valued Gateway Client
Last saved by: Christina Pirelli
Company: InfoPros

Long Swimming Pool Steel, Inc. Employment Application 
An Equal Opportunity Employer

Please Print 
__/__/__	___________________	___________________	__ 
Date	Last Name 		First Name		Middle 
Present Address
______________________________	_______________	___ 	_____-____ 
No. & Street				City		State	 Zip 
Permanent Address (if different from present address)
______________________________	_______________	___ 	_____-____ 
No. & Street				City	 	State	 Zip 
(___) ________	(___) ________		___-__-____ 
Business Phone		Home Phone		Social Security Number 
Employment Desired       
Position applying for:	 ______________________________________________
Personal Information 
Have you ever applied to or worked for Long Swimming Pool Steel before?	  Yes  No
If yes, when?	___________________________________ 
Do you have any friends or relatives working for	Long Swimming Pool Steel? 	  Yes  No 
If yes, state name(s) and relationship:
________________________________________		_______________ 
Name		Relationship 
________________________________________		_______________ 
Name		Relationship 

Why are you applying for work at Long Swimming Pool Steel? 
	____________________________________________________________ 
If hired, would you have a reliable means of transportation to and from work? 	  Yes    No 
Are you at least 18 years old? (If under 18, hire is subject to verification that you are of 
minimum legal age.) 	  Yes    No 
If hired, can you present evidence of your U.S. citizenship or proof of your legal right to live 
and work in this country? 	  Yes    No 
Are you able to perform the essential functions of the job for which you are applying, either 
with or without reasonable accommodation?  	  Yes    No 

If no, describe the functions that cannot be performed.
____________________________________________________________ 
____________________________________________________________ 
(Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Hire is subject to passing a medical examination, drug test and to skill and agility tests.) 

Have you ever been convicted of a criminal offense (felony or serious misdemeanor)? (Convictions for 
marijuana-related offenses that are more than two years old need not be listed.)	  Yes    No 
If yes, state nature of the crime(s), when and where convicted and disposition of the case.

	____________________________________________________________ 
	____________________________________________________________ 

(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The nature of the offense, date of the offense, the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.) 

Education, Training and Experience 
School 	Name 			No. of years	Did you	Degree
	and Address			Completed	Graduate?	or Diploma 
High 	______________________________	___	 Yes  No	________ 
School 	Name 
	______________________________ 
	Address 
	_______________	___	_____-____ 
	City	State	Zip 
College/	______________________________	___	 Yes  No	________ 
University 	Name 
	______________________________ 
	Address 
	_______________	___	_____-____ 
	City	State	Zip 
Vocational/	______________________________	___	 Yes  No	________ 
Business 	Name 
	______________________________ 
	Address 
	_______________	___	_____-____ 
	City	State	Zip 
	City	State	Zip 

Employment History
List below all present and past employment starting with your most recent employer (last five years is sufficient). Account for all periods of unemployment. You must complete this section even if attaching a resume.       
______________________________	(___) ________ 
Name of Employer 	Telephone No.
______________________________	______________________________ 
Type of Business	Your Supervisor's Name	 
______________________________	_______________	___	_____-____ 
Address & Street	City	 State	 Zip 
Dates of Employment:	__/__/__	__/__/__	Weekly Pay:	________	________ 
	From	To		Starting	Ending 
____________________________________________________________ 
Your Position and Duties 
____________________________________________________________ 
Reason for Leaving 
May we contact this employer for a reference? 	  Yes    No 
______________________________	(___) ________ 
Name of Employer 	Telephone No.
______________________________	______________________________ 
Type of Business	Your Supervisor's Name	 
______________________________	_______________	___	_____-____ 
Address & Street	City	 State	 Zip 
Dates of Employment:	__/__/__	__/__/__	Weekly Pay:	________	________ 
	From	To		Starting	Ending 
____________________________________________________________ 
Your Position and Duties 
____________________________________________________________ 
Reason for Leaving 
May we contact this employer for a reference? 	  Yes    No 

______________________________	(___) ________ 
Name of Employer 	Telephone No.
______________________________	______________________________ 
Type of Business	Your Supervisor's Name	 
______________________________	_______________	___	_____-____ 
Address & Street	City	 State	 Zip 
Dates of Employment:	__/__/__	__/__/__	Weekly Pay:	________	________ 
	From	To		Starting	Ending 
____________________________________________________________ 
Your Position and Duties 
____________________________________________________________ 
Reason for Leaving 
May we contact this employer for a reference? 	  Yes    No
Note: Attach additional page(s) if necessary.

References 
List below three persons not related to you who have knowledge of your work performance within the last three years.     
___________________	___________________		(___) ________ 
First Name	Last Name			Telephone No 
______________________________	_______________	___	_____-____ 
Address & Street		City		State	 Zip 
_____________________________	__  
Occupation		No. of Years Acquainted 
 ___________________	___________________		(___) ________ 
First Name	Last Name			Telephone No 
______________________________	_______________	___	_____-____ 
Address & Street		City		State	 Zip 
_____________________________	__  
Occupation		No. of Years Acquainted 
___________________	___________________		(___) ________ 
First Name	Last Name			Telephone No 
______________________________	_______________	___	_____-____ 
Address & Street		City		State	 Zip 
_____________________________	__  
Occupation	 	No. of Years Acquainted 
Please Read Carefully, Initial Each Paragraph and Sign Below 

______	I hereby certify that I have not knowingly withheld any information that might adversely affect my
 Initials	chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

______	I hereby authorize the company to thoroughly investigate my references, work record, education and
 Initials	other matters related to my suitability for employment and, further, authorize the references I have listed to disclose to the company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.

______	I understand that nothing contained in the application, or conveyed during any interview which may
 Initials	be granted or during my employment, if hired, is intended to create an employment contract between me and the company. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or the company, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the company’s designated representative.

_____
Initials 	Should a search of public records (including records documenting an arrest, indictment, conviction, civil judicial action, tax lien, credit report or outstanding judgment) be conducted by internal personnel employed by the Company. I am entitled to copies of any such public records obtained by the Company unless I mark the check box below. If I am not hired as a result of such information, I am entitled to a copy of any such records even though I have checked the box below.

	I waive receipt of a copy of any public record described in the paragraph above

____________ 	____________________________________________________________________
Date	Applicant’s Signature

Application/Short		3/07