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*
Full Name*
E-Mail Address
Present Address*
Permanent Address*
Home Phone Number*
Cell Number
Position Desired*
Which Stutzmans Location are you applying for?
Preferred Work Schedule*
Date You Can Start*
Are you willing to work overtime if requested?*
No
Yes
Salary Range Desired
Are you employed now?*
No
Yes
Have you ever been employed by this company before?*
No
Yes
If yes, give date
Are you 18 years of age or older?*
No (proof may be required if employed)
Yes
How were you referred to us?*
Are you legally able to be employed in this country?*
No (proof may be required if employed)
Yes
Do you have a current drivers license?*
Commercial*
No
Yes
(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?
No
Yes
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)?
EDUCATION
High School
Years Completed & Year Graduated
College
Years Completed & Year Graduated & Name of Degree/Diploma
Trade or Business School
Years Completed & Year Graduated & Name of Degree/Diploma
List any special honors, certificates, awards or training you have received
Note any additional information that may be helpful to us in considering your application
What has motivated you to submit an application with Stutzmans Greenhouse?
In what way would Stutzmans benefit by having you as an employee?
PERSONAL REFERENCES - List three persons who are NOT RELATED to you
Please list their Name, Address, Phone Number, Business and Years Acquainted
EMPLOYMENT EXPERIENCE - Start with your present or last job.
#1 Dates Employed - From & To, Employer, Supervisor, Address & Phone Number
Position - Work Performed
Salary - Starting & Ending
Reason For Leaving
May we contact
No
Yes
#2 Dates Employed - From & To, Employer, Supervisor, Address & Phone Number
Position - Work Performed
Salary Starting & Ending
Reason for Leaving
May we contact?
No
Yes
#3 Dates Employed From & To, Employer, Supervisor, Address & Phone Number
Position - Work Performed
Salary Starting & Ending
Reason for Leaving
May we Contact?
No
Yes
Have you been convicted of a felony or misdemeanor?
No
Yes
(Convictions are not a bar to employment in all cases. Each situation is evaluated individually.)
If yes, Please describe:
"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.
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.
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.
I understand that as a condition of employment, I may be required to undergo a medical examination and substance test.
Date
Signature
800-279-4505
