| PERSONAL TRAINING & WEIGHT LOSS

The Fitness Center
3900 Montclair Road, Suite 210
Birmingham, AL 35213
870-1121

Application for Employment

PRE-EMPLOYMENT QUESTIONNAIRE EQUAL OPPORTUNITY EMPLOYER

Today's Date:
PERSONAL INFORMATION
Last Name First Name
Social Security #
Present Address
City State Zipcode
Permanent Address
City State Zipcode
Phone Number with Area Code
Referred by:
EMPLOYMENT DESIRED
Position Date You can Start
Salary Desired
Are You Employed? Yes No
If so, may we inquire of your present employer? Yes No
Ever applied to this company before? Yes No When?
EDUCATION HISTORY
NAME & LOCATION OF SCHOOL		YEARS ATTENDED	DID YOU GRADUATE?	SUBJECTS STUDIED
Grammar School
High School
College
Trade, Business or Correspondence School

GENERAL INFORMATION
Subjects of Special Study/Research Work or Special Training/Skills:
U.S. Military or Naval Service? Yes No Rank

FORMER EMPLOYERS (List below last four employers, starting with last one first.)
1. Date: From (month & year) To:
Name and Address of Employer:
Salary:	Position:	Reason for Leaving:
2. Date: From (month & year) To:
Name and Address of Employer:
Salary:	Position:	Reason for Leaving:
3. Date: From (month & year) To:
Name and Address of Employer:
Salary:	Position:	Reason for Leaving:
4. Date: From (month & year) To:
Name and Address of Employer:
Salary:	Position:	Reason for Leaving:

REFERENCES Give below the names of three persons not related to you, whom you have known at least one year.
NAME	ADDRESS	BUSINESS	YEARS KNOWN
1.
2.
3.

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 any 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."
Date Signature (completion will act as your digital signature.)