Employment Application. // Origin Land Surveying and Mapping, Inc.

This is out Pre-Employment Questionnaire, please complete this application, and we will contact you are soon as possible.

An Equal Opportunity Employer

Personal Information
Date:		Email Address:
First Name:		Phone No.:
Last Name:

Present Address:
Street:		State:
City:		Zip:
Are you 18 years old or older?	Yes No	Are you legally eligible for employment in the United States?	Yes No

Employment Desired
Position:		Date You Can Start:
Salary Desired:
Are you employed now?	Yes No	If so, may we inquire of your present employer?	Yes No
How many hours per week would you like to work?		Date available to start?

*Education*
	Name/Location of School	# of Years Attended	Did you graduate?	Subjects Studied
Grammar School			Yes No
High School			Yes No
Collage			Yes No
Trade, Business or Correspondence School			Yes No


*General*
Subjects of special study or research work:
U.S. Military or Naval Service:
Rank:
Present Membership in National Guard or Reserves:

Former Employers
(List below last three employers, starting with last one first.)

1.	Employer:
	Position:
	Employment Dates:	From:
		To:
	Address:
	Wage/Salary		$
	Reason for leaving:

2.	Employer:
	Position:
	Employment Dates:	From:
		To:
	Address:
	Wage/Salary		$
	Reason for leaving:

3.	Employer:
	Position:
	Employment Dates:	From:
		To:
	Address:
	Wage/Salary	Start:	$
	Reason for leaving:

References: Give the names of three people not related to you, whom you have known at least one (1) year.

1.	Name:	2.	Name:	3.	Name:
	Address:		Address:		Address:
	Phone #:		Phone #:		Phone #:
	Business:		Business:		Business:
	Yrs Acquainted:		Yrs Acquainted:		Yrs Acquainted:

Physical Record
Do you have any physical limitations that preclude you from performing any work for which you are being considered?	Yes No	In case of emergency, notify:
		Name:

Please describe:		Address:
If yes, what can be done to accommodate your limitation?		Phone:

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 shall 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 they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you.
I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without prior notice.

Your Initials:
Date:

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Employment Application. // Origin Land Surveying and Mapping, Inc.

Former Employers