Fr Test

DATE INTERVIEW: TEST: IN CLASS

TIME PASS/FAIL PASS/FAIL SIGNATURE

Have you ever been on a hearing Yes Why:

at your previous job

No

if yes, why?

Have you ever been dismissed at Why:

your previous job?

Yes No

If Yes why?

Health: Heart High Blood Eye sight Any other medical Condition: Pressure: Problems: conditions:

Yes Yes Yes Please list:

No No No

Do you use any Chronic

medication and how often

must it be collected?

YES NO

HAVE YOU APPLIED FOR A JOB

AT HESTONY BEFORE? IF SO,

WHEN?

WHAT HAPPENED LAST TIME?

, the applicant indicated above, herewith signed below, declare all information to be true and correct. I hereby give permission to check my criminal record. I agree thatl will not be appointed if it contradicts the information on this application. I also agree to voluntarily undergo a pre-employment polygraph. I agree

that if I fail this test I will not be appointed. SIGNATURE: DATE:

50UTH

INIRVDW

ARRPAl

APPICANt's KEPENENCES LASt WO COMPANIE

A INAD

A/tAlI

Meuae Mt eythity this side: FOR OFFICE USE ONLY

MAAM CUMNY

HWN

AIE EMMbveD FM

YPE VEHCIE DIVEN (EG. sUPENUINN):

MANE OF VEHICE DRIVEN (EG. OLvW):

ONS LOADED (FR 14tVN

WHAT DND YOU tMANSORT:

At WHAT Towns DD YOu OFFLOAD:

REASON FO LEAVING

ANDINE TEL NO. oretumowe

CONTACT PERSON

cONTACT PNSON'S POSIttoN:,

NAME OY CUwANY

towN

PHOVINCE

DATE EMPoYED - FROM

DATE EMPAOYED O

TYPE VENICLE DRIVEN (EG. SUPERUINK)

MARE OF VEHICLE DRIVEN (EG. VOLVO)J

rONS LOADED (EG. 14TON):

WHAT DID YOu TRANSPORT

AT WHAT ToWNS DID You OFFLOAD

REASON FOR LEAVING:

LANDLINE TEL NO. (NOr CEumoN)

cONTACT PRsON

CONTACT PERSON'S PosiTION:

the appetkant indkcated ebove. herewith shgned below. derlare all mtomaton to be true andeonect SIGNATUR DAI

i

Contact this candidate