APPLICATION FOR EMPLOY MENT

(Pre-Employment Questionnaire)
Questionnaire) (Ferme
(Pre-Employment(Pre-Employment (An Ste-Sophie)
Equal Inc)Employer)
Opportunity
Questionnaire)

PERSONAL INFORMATION
DATE

LAST
Sex
SOCIAL SECURITY
NAME NGUYEN BINH TIEN NUMBER Male
LAST FIRST MIDDLE

PRESENT ADDRESS
PRESENT ADDRESS Hoang Van Thu ward Bac Giang city
STREET CITY STATE ZIP

PERMANENT ADDRESS Hoang Van Thu Bac Giang city

waSTREET CITY STATE ZIP

PHONE NO. 0979785452 ARE YOU 18 YEARS OR OLDER? Yes ❑ No ❑

Email address
ARE YOU PREVENTED FROM LAWFULLY BECOMING EMPLOYED
ARE YOU CURRENTLY EMPLOYED

ARE
IN YOU
THIS
EMAIL IN CANADA
COUNTRY
ADDRESS BECAUSE OF VISA OR IMMIGRATION STATUS? Yes ❑ yes No ❑

EMPLOYMENT DESIRED
DATE YOU SALARY
POSITION Production worker CAN START 01/09/2021 DESIRED 4,000

FIRST
IF SO MAY WE INQUIRE
ARE YOU EMPLOYED NOW? Yes OF YOUR PRESENT EMPLOYER? Yes

EVER APPLIED TO THIS COMPANY BEFORE? No WHERE? WHEN?

REFERRED BY

*NO OF
EDUCATION NAME AND LOCATION OF SCHOOL YEARS *DID YOU SUBJECTS STUDIED
ATTENDED GRADUATE?

GRAMMAR SCHOOL

HIGH SCHOOL

MIDDLE
COLLEGE THAI NGUYEN UNIVERSITY OF 05 Yes Information and
TRADE, BUSINESS OR
INFORMATION AND techno
CORRESPONDENCE COMMUNICATION TECHNOLOGY
SCHOOL

GENERAL
SUBJECTS OF SPECIAL STUDY OR RESEARCH WORK

SPECIAL SKILLS

ACTlVITIES: (CIVIC ATHLETIC ETC.)

EXCLUDE ORGANIZATIONS, THE NAME OF WHICH INDICATES THE RACE, CREED. SEX. AGE, MARITAL STATUS, COLOR OR NATION OF ORIGIN OF ITS MEMBERS.

MILITARY
U. OR OR
S MILITARY PRESENT MEMBERSHIP IN
NAVAL
NAVALSERVICE
SERVICE No RANK NATIONAL GUARD OR RESERVES

*This
*This form
*This form has
formhas been
hasbeen revised
beenrevised to
revisedto comply
tocomply with
complywith the
withthe provisions
theprovisions ofofof
provisions the
the Canada
Americans
the with
withDisabilities
Employment Disabilities
with Act
Act Act
Disabilities
and the
and the final
final regulations
regulations and
andinterpretive
interpretiveguidance
guidancepromulgated
promulgatedbybythe theEEOC
EEOCononJuly
July26.
26.1991.
1991.

FSSI FORM
TOPS FORM7438)
3285 (92-8) (CONTINUED ON OTHER SIDE) Ferme Ste-Sophie
LITHO IN U.S.A. Inc
FORMER EMPLOYERS (LIST BELOW LAST THREE EMPLOYERS, STARTING WITH LAST ONE FIRST).
DATE
MONTH AND YEAR NAME AND ADDRESS OF EMPLOYER SALARY POSITION REASON FOR LEAVING
FROM 07/2020
ACteck - Dai Dong Industrial Park. Sales
TO executive
date
FROM
03/2020 Nam Hong Co., Ltd Intern
TO
07/2020
FROM
04/2019 Viettel Thai Nguyen Collaborator Project finished
TO
08/2019
FROM
TO

WHICH OF THESE JOBS DlD YOU LIKE BEST?

WHAT DlD YOU LIKE MOST ABOUT THIS JOB?

REFERENCES: GIVE THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR.
YEARS
NAME ADDRESS BUSINESS ACQUAINTED
1

THE FOLLOWING STATEMENT APPLIES IN: MARYLAND & MASSACHUSETTS. [Fill in name of state.)
IT IS UNLAWFUL IN THE STATE OF ________________________ TO REQUIRE OR ADMINISTER A LIE DETECTOR TEST
AS A CONDITION OF EMPLOYMENT OR CONTINUED EMPLOYMENT. AN EMPLOYER WHO VIOLATES THIS LAW SHALL
BE SUBJECT TO CRIMINAL PENALTIES AND CIVIL LIABILITY.
Signature of Applicant
IN CASE OF
EMERGENCY NOTIFY
NAME ADDRESS PHONE NO.

"I CERTIFY THAT ALL THE INFORMATION SUBMITTED BY ME ON THIS APPLICATION IS TRUE AND COMPLETE, AND I UNDERSTAND THAT
IF ANY FALSE INFORMATION, OMISSIONS, OR MISREPRESENTATIONS ARE DISCOVERED, MY APPLICATION MAY BE REJECTED AND, IF I
AM EMPLOYED. MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME.
IN CONSIDERATION OF MY EMPLOYMENT, I AGREE TO CONFORM TO THE COMPANY'S RULES AND REGULATIONS, AND I AGREE THAT
MY EMPLOYMENT AND COMPENSATION CAN BE TERMINATED, WITH OR WITHOUT CAUSE. AND WITH OR WITHOUT NOTICE, AT ANY
TIME, AT EITHER MY OR THE COMPANY'S OPTION. I ALSO UNDERSTAND AND AGREE THAT THE TERMS AND CONDITIONS OF MY
EMPLOYMENT MAY BE CHANGED, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, AT ANY TIME BY THE COMPANY. I
UNDERSTAND THAT NO COMPANY REPRESENTATIVE, OTHER THAN IT'S PRESIDENT, AND THEN ONLY WHEN IN WRONG AND SIGNED
BY THE PRESIDENT, HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIC PERIOD OF TIME,
OR TO MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING.

DATE SIGNATURE

DO NOT WRITE BELOW THIS LINE

INTERVIEWED BY: DATE:

REMARKS:

NEATNESS ABILITY

HIRED: ❑ Yes ❑ No POSITION DEPT.

SALARY/WAGE DATE REPORTING TO WORK

APPROVED: 1. 2. 3
EMPLOYMENT MANAGER DEPT. HEAD GENERAL MANAGER

This form has been designed to strictly comply with State and Federal fair employment practice laws prohibiting employment discrimination. This Application for Employment Form
This
is form
sold for has beenuse
general designed to strictly
throughout complyStates.
the United with State
TOPSand Federalno
assumes fairresponsibility
employment forpractice laws prohibiting
the inclusion employment
in said form discrimination.
of any questions which, when asked by the Employer of the
Job Applicant, may violate State and/or Federal Law.
 Wewelcome
We welcome your
your application
application for employment at Ferme Ste-Sophie Inc
for employment
We welcome your application for employment at Southern Platte Fire Protection
We are proud
District that ourreferred
(hereinafter success istothe
asresult of the quality
the Company). We and caliber
are proudofthat
our employees.
our successIn pursuit of
excellence, authorize
is the result a pre-employment
of the quality and caliber of our verification
employees. of Inthe background
pursuit information
of excellence,
authorize
we require,a aspre-employment verification of
a condition of employment, the background
all applicants information
must consent to and
submitted on their applications and resumes.
authorize a pre-employment verification of the background information
submitted on their applications and resumes.

The
Thefollowing
followinginformation is used
information for identification
is used for identification
purposes in verifying background information.

Printed Name______________________ Date__________

Signature________________________________________
SS#____________________________________________
List any cities and states where you previously resided:
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________