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APPLICATION FOR EMPLOYMENT   Pre-Employment Questionnaire
Equal Opportunity Employer
PERSONAL INFORMATION
Last Name *
  First Name *
  SSN
Present Address
  City
  State
  Zip
Permanent Address
  City
  State
  Zip
Phone
  Referred By
EMPLOYMENT DESIRED
Position Desired
  Date You Can Start
  Salary Desired
Are You Employed
Yes No 		  If So, May We Inquire of Your Present Employer
Yes No
EDUCATION HISTORY
Name & Location of School   Years   Graduate?   Subjects Studied
High School
    Y N  
College
    Y N  
Trade, Business, Correspondence School
    Y N  
GENERAL INFORMATION
Subjects of Special Study/Research, Work, or Special Training/Skills *
U.S. Miitary or Naval Service
  Rank
FORMER EMPLOYERS (List below last four employers starting with last one first)
Start (MM/YYYY)
  End (MM/YYYY)
  Name/Address of Employer
  Salary
  Position
  Reason for Leaving
         
         
         
REFERENCES Give below the names of three people not related to you whom you have known at least one year
Name
  Address
  Business
  Years Known
     
     
UPLOAD RESUME (.doc, .docx, or .pdf only)
AUTHORIZATION
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 and employers listed above to give you and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.
I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.
This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.
Signature

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Energy Exchanger
1844 N. Garnett Road
Tulsa, Oklahoma 74116-1612 Phone: 918.437.3000
Fax: 918.437.7144