Confidential Questionnaire

Personal Data

Name:
Address:
City: State: Zip:
Home Phone: E-mail:
Office Phone: Fax:
Marital Status: Single Married Divorced Separated Widowed
# of Children: Ages:
Height: Weight: Health:

Education

Degree/s and Year/s Completed: Other Training and Education:

Current Position

Company:
City: State:

Position: Report to (Name and Position):
Dates Employed
From: To:
Compensation
Base Salary: Incentive Payments:
Corporate Name/Location:
# of Employees: Annual Sales:
Benefits Progression from Beginning of Employment to Present:

Self Awareness

Objectives and Goals (Where do you see yourself in 4-5 years?): Strengths: Need For Improvement:

Criteria

Industry Preference:

Relocation/Community Preference(s):

Present Living Situation: Own Home/Condo Rent Home/Apartment Other

Type of Position for Which You are Best Suited:

Do You Foresee Any Problems in Making A Change:

Minimum Compensation: Travel Considerations:

Where have you interviewed in the past three months:

Registered with Other Employment Agencies: Yes No If yes, with whom:

References—Please submit list of (3) Peer, Supervisor, Personal Include: Name, Address, City, State, Zip, Phone and Relationship.

Referrals—Those you know that are looking and those you think might be looking. Include: Name, Address, City, State, Zip, Phone.

Thank you for completing this Confidential Questionnaire.

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