PRE-EMPLOYMENT APPLICATION

Our company is an equal opportunity employer and will consider all applicants for all positions equally without regard to their race, sex, age, color, religion, national origin, veteran status or any disability as provided in the American's With Disabilities Act.

This application will be given every consideration, but its receipt does not imply that the applicant will be employed. Each question should be answered in a complete and accurate manner as no action can be taken on this application until all questions have been answered.

P.O. Box 790

LACOMBE, LA 70445

OFFICE (985) 882-6101

FAX (985) 882-6183

MILITARY

Service Branch:	Date Entered:	Date Separated:
Final Rank:	Type of Discharge:
Have you ever served in the military ? Yes No

WORK HISTORY

List names of employers in consecutive order with present or last employer first. Account for all periods of time, including military service and any periods of unemployment. If self-employed, give firm name and supply business references.

NAME AND ADDRESS OF EMPLOYER

Employer Contact
Employer Contact Number

DATES EMPLOYED

From:	To:
Month:	Month:
Year :	Year :

Pay
Start:
Ending:

NATURE OF BUSINESS

TITLE / POSITION

NAME AND TITLE OF LAST SUPERVISOR

REASON FOR LEAVING

DUTIES:

NAME AND ADDRESS OF EMPLOYER

EMPLOYER CONTACT EMPLOYER CONTACT NUMBER

DATES EMPLOYED

From:	To:
Month:	Month:
Year :	Year :

Pay
Start:
Ending:

NATURE OF BUSINES

TITLE/POSITION

NAME AND TITLE OF LAST SUPERVISOR

REASON FOR LEAVING

DUTIES:

NAME AND ADDRESS OF EMPLOYER

Employer Contact
Employer Contact Number

DATES EMPLOYED

From:	To:
Month:	Month:
Year :	Year :

Pay
Start:
Ending:

NATURE OF BUSINESS

TITLE / POSITION

NAME AND TITLE OF LAST SUPERVISOR

REASON FOR LEAVING

DUTIES:

SUPPLEMENTAL EMPLOYMENT INFORMATION:

If you worked in any of your previous positions under another name, please give that name(s)
Are you presently employed? Yes No
If Yes, may we contact your present employer? Yes No
Have you ever been fired, or asked to resign, from a job? Yes No
If Yes, please explain

SPECIAL SKILLS:

Do you type? Yes No Words per minute:
Have you had any computer or word processing experience or training? Yes No
If Yes, please describe
What language do you speak fluently?
Use this space below to describe why you are interested in working for our company and list those skills and abilities which you feel particularly qualify you for a position with us.

REFERENCES

Give three (3) references, not relatives or former employees.

NAME

ADDRESS

PHONE

OCCUPATION

AUTHORIZATION TO OBTAIN INFORMATIONPRIVACY ACT STATEMENT AND RELEASE

To Whom It May Concern:
This authorization and release, or photocopy hereof, is unlimited as to time.I authorize and release you to furnish any and all information to Python Corporation; P.O. Box 790; Lacombe, LA 70445 and/or their agents. Regarding my character, health, wealth, finances, civil and criminal suits, credit, medical records, birth records, state and federal records, accident reports, personal records, pre-employment records and/or any other information that might be necessary for Python Corporation and/or their agents to complete their investigation.

SIGNATURE DATE ADDRESS
CITY, STATE & ZIP CODE DATE OF BIRTH

AFFIDAVIT

I certify that my answers to the foregoing questions are true and correct without any consequential omissions of any kind whatsoever. I understand that if I am employed, any false, misleading or otherwise incorrect statements made on this application form or during any interviews may be grounds for my immediate discharge.

I hereby authorize the Company to contact any company or individual it deems appropriate to investigate my employment history, character and qualifications and I give my full and complete consent to their revealing any and all information they wish as a result of this investigation. In addition, I hereby waive my right to bring any cause of action against these individuals for defamation, invasion of privacy or any other reason because of their statements.

I agree that, if I am employed, I will abide by all the rules and regulations of the company. I understand that the taking of drug and alcohol testes, when given pursuant to company policy, are a condition of continued employment and refusal to take such tests when asked will be grounds for my immediate termination. I further understand that nobody in the company is authorized to enter into any written or verbal employment contracts with me for any definite period of time without the express written consent of the President of the Company. I also understand that my employment is “at-will” and may be terminated by myself or by the company at any time for any reason at all, with or without prior notice.

SIGNATURE DATE

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COMPANY USE ONLY

Interviewed By: Interviewers remarks:
Is the operation of a company vehicle a job requirement? Yes No If yes to above, has a request for driver’s record been made? Yes No

Quick Links

If you have issues with the website, please contact us webmaster@python-corp.com

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Name		Home Phone
Present Address		E-Mail *
Are you over 18? Yes No
Are you a citizen of the U.S., or do you have the legal right to be employed in the United States? Yes No
Have you ever been convicted of any crime (excluding minor traffic violations) including
DWI? Yes No
If yes, state the offense, location, date and disposition
Would you be willing to relocate? Yes No
Driver's License:	State:	Type:	#:
Currently Valid? Yes No

Full Time Part Time Temporary Summer employment
Position applied for: Certified Not Certified	Salary Desired:	Available to start:
Have you ever applied to our company before Yes No
Have you ever worked for our company before Yes No
If your answer to either of the above questions Yes, state when and where you applied and/or worked.
If your answer to either of the above questions Yes, state when and where you applied and/or worked.
How did you learn of our company and/or position?
Are you now, or do you expect to be, working in any other business or job? Yes No
Are there any days or hours you would be unable or unwilling to work? Yes No
If Yes, please specify those days or hours.

High School	From: To:	Graduate Yes No	Diploma Yes No
College	From: To:	Graduate Yes No	Degree Yes No
Course(s) Studied:
Trade School	From: To:	Graduate Yes No	Diploma Yes No
Course(s) Studied:

If you did not graduate, why did you leave high school or college?
Are you planning to pursue further studies? Yes No
If so, when, where and what courses?
List any scholastic honors, offices held and activities involved in during high school and college.
List any describe other School or Specialized Training?

Would you be willing and able to perform all of the tasks required by the job you are applying for? Yes No
If No, please explain
Have you filed any type of fraudulent claim against any of your present or past employers? Yes No
If Yes, please explain
Will you abide by the safety rules of this company? Yes No
Have you ever been disciplined for violating company safety rules or regulations? Yes No
If Yes, please explain
How many days of work (or school) have you missed in the last two years?
How many times have you been late for work (or school) in the last two years?
Would you be willing & able to work on time every day on a regular & consistent basis? Yes No
If Yes, please explain

PRE-EMPLOYMENT APPLICATION

PERSONAL

EMPLOYMENT DESIRED

MILITARY

EDUCATION

CAPABILITY / RELIABILITY

WORK HISTORY

SUPPLEMENTAL EMPLOYMENT INFORMATION:

SPECIAL SKILLS:

REFERENCES

AUTHORIZATION TO OBTAIN INFORMATIONPRIVACY ACT STATEMENT AND RELEASE

AFFIDAVIT

COMPANY USE ONLY

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PRE-EMPLOYMENT APPLICATION

PERSONAL

EMPLOYMENT DESIRED

MILITARY

EDUCATION

CAPABILITY / RELIABILITY

WORK HISTORY

SUPPLEMENTAL EMPLOYMENT INFORMATION:

SPECIAL SKILLS:

REFERENCES

AUTHORIZATION TO OBTAIN INFORMATIONPRIVACY ACT STATEMENT AND RELEASE

AFFIDAVIT

COMPANY USE ONLY

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