Tops Form 3285 89 B – Fill Out and Use

GENERAL

SUBJECTS OF SPECIAL STUDY OR RESEARCH WORK

SPECIAL SKILLS

ACTIVITIES (CIVIC, ATHLETIC, ETC)

EXCLUSIVE ORGANIZATIONS, THE NAME OF WHICH INDICATES THE RACE, GREED SEX, AGE, MARITAL STATUS, COLOR OR NATION OF ORIGIN OF ITS MEMBERS

U.S. MILITARY OR	RANK	PRESENT MEMERSHIP IN
NAVAL SERVICE		NATIONAL GUARD OR RESERVES

*The Age Discrimination in Employment Act of 1987 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age

TOPS	TOPS	(CONTINUED ON OTHER SIDE)	LITHO IN U.S.A
	FORM 3285 (89-8)

PERSONAL EMPLOYERS (LIST BELOW LAST THREE EMPLOYERS, STARTING WITH LAST ONE FIRST).

	DATE,	NAME AND ADDRESS OF EMPLOYER	SALARY	POSITION	REASON FOR LEAVING
	MONTH AND YEAR
	FROM
	TO
	FROM
	TO
	FROM
	TO
	FROM
	TO

WHICH OF THESE JOBS DID YOU LIKE BEST?

REFERENCES: GIVE THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR

1.

2.

3.

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 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 LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY HAVE, AND RE- LEASE ALL PARTIES FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM FURNISHING SAME TO YOU.

I UNDERSTAND AND AGREE THAT, IF HIRED, MY EMPLOYMENT IS FOR NO DEFINITE PERIOD AND MAY, REGARDLESS OF THE DATE OF PAYMENT OF MY WAGES AND SALARY, BE TERMINATED AT ANY TIME WITHOUT PRIOR NOTICE AND WITHOUT CAUSE.”

DATESIGNATURE

	DO NOT WRITE BELLOW 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 is sold for general use throughout the United States. TOPS assumes no responsibility for the inclusion in said form of any questions whish, when asked by the Employment of the Job Applicant, may violate State and/or Federal Law