Application For Employment

(Pre-Employment Questionnaire)
An Equal Opportunity Employer

Personal Information

First Name:
 Last Name:
 Email:
Street Address:
City:
 State:
 Zip Code:
Phone Number:
 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:
 Date you can start:
 Salary Desired:
Are you currently employed?
Yes       No 		If yes, who is your present employer? (optional)
     
Have you applied to RI Rehab before? Yes       No Where?
 When?

Referred By:

Education - High School

Name of School:

 Location of School:
 Year Graduated:

Education - College

Name of School:

 Location of School:
 Year Graduated:
Degree Obtained:
 Major:
  

Education - Graduate School

Name of School:

 Location of School:
 Year Graduated:
Degree Obtained:
 Major:
  

Please Answer the Following Questions:

Have you ever been on probation or sentenced to jail/prison as a result of a felony conviction or guilty plea to a felony charge? Yes       No    [If "Yes," please provide the following information:]
     
Law Enforcement Authority:
Offense:
 Date of Offense:
 
Place and Disposition of Case:
 
Have you ever been fired from a job or resigned to avoid dismissal? If "Yes," please explain. A "Yes" answer will not necessarily bar you from state employment. Yes       No

Former Employers
(List below your last three employers,
starting with the most recent one first.)

Dates Employed To: Dates Employed From:
 Company Name:
Employer Name:
 Employer Address:
Position:
 Salary:
 Reason for Leaving:
     
Dates Employed To: Dates Employed From:
 Company Name:
Employer Name:
 Employer Address:
Position:
 Salary:
 Reason for Leaving:
     
Dates Employed To: Dates Employed From:
 Company Name:
Employer Name:
 Employer Address:
Position:
 Salary:
 Reason for Leaving:

References
(Give the names of three persons not related to you,
whom you have known at least one year.)

Name:
 Address:
Business:
 Years Acquainted:
 Phone Number:
   
Name:
 Address:
Business:
 Years Acquainted:
 Phone Number:
   
Name:
 Address:
Business:
 Years Acquainted:
 Phone Number:
 
          
 
 
 
 
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