Job Application

We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orienation, or any other legally protected status

Position(s) Applied For:

Email:

Name:

How did you learn about us?
 Advertisement Friend Walk In Employment Agency Relative Other

Address:

City:

State:

Zip Code:

Phone:

Social Security #:

If you are under 18 years of age, can you provide required proof of your eligibility to work?
 Yes No

Have you ever filed an application with us before?
 Yes No

If yes, give date:

Have you ever been employed with us before?
 Yes No

If yes, give date:

Are you currently employed?
 Yes No

May we contact your present employer?
 Yes No

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?
Proof of citizenship or immigration status will be required upon employment.

 Yes No

On what date would you be available for work?

Are you available to work:
 Full Time Part Time Shift Time Temporary

Are you current on "Lay-off" status and subject to recall?
 Yes No

Can you travel if a job requires it?
 Yes No

Have you been convicted of a felony within the last 7 years?
Conviction will not necessarily disqualify an applicant from employment

 Yes No

If yes, please explain:

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Education
Please list the schools name, address, course of study, years completed, and display degree for each school in the appropriate school field

Elementary School:

High School:

Undergraduate College:

Graduate Professional:

Other (Specify):

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Indicate any foreign languages you can speak, read and or write

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Describe any specialized training, apprenticeship, skills, and extra-curricular activities.

Describe any job-related training received in the United States military.

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    Employment Experience

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.

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Employer:

Telephone:

Address:

Job Title:

Supervisor:

Dates Employed:
to

Hourly Rate/Salary
Starting: Final:

Reason for Leaving?

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Employer:

Telephone:

Address:

Job Title:

Supervisor:

Dates Employed:
to

Hourly Rate/Salary
Starting: Final:

Reason for Leaving?

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Employer:

Telephone:

Address:

Job Title:

Supervisor:

Dates Employed:
to

Hourly Rate/Salary
Starting: Final:

Reason for Leaving?

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Employer:

Telephone:

Address:

Job Title:

Supervisor:

Dates Employed:
to

Hourly Rate/Salary
Starting: Final:

Reason for Leaving?

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    Additional Information

Other Qualifications
Summarize special job-related skills and qualifications acquired from employment or other experience

Specialized Skills:
 Calculator Typewriter Lotus 1-2-3 PBX System Wordperfect CRT PC Fax

    Check Skills/Equipment Operated:

Production/Mobile Machinery (list):



Other (list):



State any additional information you feel may be helpful to us in considering your application.

Note to Applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.

Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the job or occupation for which you have applied?
 Yes No

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    References:

1)

2)

3)

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    Applicant Data Record

(This record will be maintained apart from your Application for Employment during the application process)

All qualified applicants are considered for employment, and employees are treated during employment without regard torace, color, religion, sex, national origin, age, citizenship, disability, or veteran status. Additionally, the Company provides reasonable accommodation to qualified individuals with disabilities.

Government regulations require [Company name] to annually report upon the ethnicity, race and gender of its employees.

To assist the Company to comply with these government regulations and reporting requirements, we request that you identify your ethnicity, race and gender below.

Submission of this information is voluntary. You will not be subjected to any adverse treatment if you do not provide the information requested. This data will be kept in a separate file from your Application for Employment.

Gender:

Ethnicity:

Race:

Applicant Survey of Veteran Status

[Company] is a federal government contractor subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended, which requires Government contractors to take affirmative action to employ and advance in employment protected veterans identified below. We request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake.

Submission of this information is voluntary. You will not be subjected to any adverse treatment if you do not provide the information requested. This data will be kept in a separate file from your Application for Employment.

If you are disabled veteran it would assist us if you tell us whether there are accommodations we could make that would enable you to perform the essential functions of the job. The information you submit will be kept confidential, except that (i) supervisors and managers may be informed regarding restrictions on the work or duties of disabled veterans, and regarding necessary accommodations; (ii) first aid and safety personnel may be informed, when and to the extent appropriate, if you have a condition that might require emergency treatment; and (iii) Government officials engaged in enforcing laws administered by the Office of Federal Contract Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed.

Veteran Category Definitions

  • Disabled Veteran -- (1) A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs, or (2) A person who was discharged or released from active duty because of a service-connected disability.
  • Recently Separated Veteran -- Any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval or air service.
  • Armed Forces Service Medal Veteran -- Any veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which and Armed Forces service medal was awarded pursuant to Executive Order 12985.
  • Active duty wartime or campaign badge veteran -- A veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized, under the laws administered by the Department of Defense.

If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below.

Voluntary Self-Identification of Disability

Why are you being asked to complete this form?

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities.i To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may
become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

How do I know if I have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

Disabilities include, but are not limited to:

  • Blindness
  • Deafness
  • Cancer
  • Diabetes
  • Epilepsy
  • Autism
  • Cerebral palsy
  • HIV/AIDS
  • Schizophrenia
  • Muscular dystrophy
  • Bipolar disorder
  • Major depression
  • Multiple schlerosis (MS)
  • Missing limbs or partially missing limbs
  • Post-traumatic stress disorder (PTSD)
  • Obsessive compulsive disorder
  • Impairments requiring the use of a wheelchair
  • Intellectual disability (previously called mental retardation)

Please check one of the boxes below:

How do I know if I have a disability?

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

iSection 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.

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I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 365 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

Accept:

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