PRE-EMPLOYMENT QUESTIONNAIRE

Please answer the following:

1)

Do you have any kind of back problems or history of back pains that could prevent you from performing the requirements of the position you are seeking?

Did you ever faint, or you ever knocked unconscious? 

2)

Are you subject to frequent headaches that could prevent you from performing the requirements of the position you are seeking?

3)

Are you able to stand for long periods of time?

4)

5)

Can you lift or carry objects on a repetitive basis?

Are you able to lift more than 20 pounds? 

6)

No

No

No

Yes

Yes

Yes

The above answers are true to the best of my knowledge and ability, and I understand that misrepresentation may be cause for dismissal if hired. I also understand that I must report any injuries to my supervisor and Human Resources.

Name:

Johnnie Mckinney

Date: