First Name

Last Name

Address

City

State

ZipCode

Phone

Alternate Phone

Street

City

Zip Code

Are you over the age of 18?

Yes No

Do you have the legal right to work in the United States?

Yes No

Have you applied for a job with us before?

Yes No

If yes, month/year

Have you ever worked for us before?

Yes No

Were you recommended by an employee of Preis PLC?

Yes No

If so, please state employee's name:

If not, how did you hear about us?

Type of employment:

Full Time Part Time Temporary

How soon can you report to work?

Rate of pay expected?

If full time, can you work overtime if asked?

Yes No

Name and Location of High School (City & State)

Years completed & GPA

Name and Location of College (City & State)

Major/Degree Subjects of Study

Years completed & GPA

Name and Location of Grad School (City & State)

Major/Degree Subjects of Study

Years completed & GPA

Name and Location of Business or Trade School (City & State)

Major/Degree Subjects of Study

Years completed/GPA

Name and Location of Professional School (City & State)

Major/Degree Subjects of Study

Years completed & GPA

Have you ever plead guilty to a crime other than a traffic violation within the last ten years?

Yes No

Have you ever been discharged or requested to resign from a position?

Yes No

Are you currently employed?

Yes No

Have you ever served in the Armed Forces?

Yes No

Date Entered:

Date Discharged

Phone:

Immediate supervisor (Name & Position):

Date hired: Date left:

Starting salary: Final salary:

Reason for leaving:

Position held:

Phone:

Immediate supervisor (Name & Position):

Date hired: Date left:

Starting salary: Final salary:

Reason for leaving?

Position held

Phone:

Immediate supervisor (Name & Position):

Reason for leaving?

Position held:

Phone:

Immediate supervisor (Name & Position):

Date hired: Date left:

Starting salary: Final salary:

Reason for leaving?

Position held:

Name:

City/State:

Phone:

Name: Name:

City/State: City/State:

Phone: Phone:

Personal Information

Previous Address

Education

General Information

Prior Employment Record

Personal References

Lafayette

New Orleans

Houston