Employment Application Employment Application Employment Application Step 1 of 6 16% Equal access to programs, services and employment opportunities is available to all persons without regard to sex (including pregnancy, sexual orientation and gender identity), race, color, religion, national origin, citizenship, age, disability, genetic information, or any other basis protected by federal, state, and/or local law. In accordance with the Americans with Disabilities Act and/or applicable state and local laws, applicants requiring reasonable accommodations for the application and/or interview process should notify the Human Resources Department. Examples of reasonable accommodations include making a change to the application process; providing written materials in an alternate format such as braille, large print or audio recording; using a sign language interpreter; using specialized equipment; or modifying testing conditions.Your Personal InformationYour Name(Required) First Middle Last Applicant ID # Your Email Address(Required) Enter Email Confirm Email Address(Required) Street Address City State / Province / Region ZIP / Postal Code Your Phone(Required) Date of Application(Required) MM slash DD slash YYYY Position you're applying for(Required) Referral Sourcee.g., Walk-in, Job Posting, Company’s Website, etc. May we contact you at work? Yes No Work PhoneBest time to call(Required) Hours : Minutes AM PM AM/PM If you are under 18 and it is required, can you furnish a work permit?(Required) Yes No N/A If no, please explain Have you submitted an application here before?(Required) Yes No If yes, give date(s) and position(s): Have you ever been employed here before?(Required) Yes No If yes, when were you employed and for how long? Is this application a request for reemployment following an extended military leave of absence from this company?(Required)If yes, additional information may be requested. Yes No Are you lawfully authorized to work in the United States?(Required) Yes No Date available for work(Required) MM slash DD slash YYYY What is your desired salary range or hourly rate of pay?(Required)Type of employment desired:(Required) Full-Time Part-Time Educational Co-Op Seasonal Temporary Will you relocate if job requires it?(Required) Yes No Will you travel if job requires it?(Required) Yes No Are there any days or times when you are unavailable to work?(Required)Other than time off for reasons related to your religion, a disability, or a medical condition Will you work overtime if required?(Required) Yes No If no, please explain: Are you able to perform the "essential functions" of the job for which you are applying (with or without reasonable accommodation)?(Required)This question is not designed to elicit information about an applicant’s disability. Please do not provide information about the existence of a disability, particular accommodation or whether accommodation is necessary. These issues may be addressed at a later stage to the extent permitted by law. Yes No Need more information about the job’s “essential functions” to respond Driver's license number:Please include issuing State – Required if driving may be required in the job for which you are applying: Have you ever been bonded?(Required) Yes No Have you entered into an agreement with any former employer or other party (such as a noncompetition agreement) that might, in any way, restrict your ability to work for our company?(Required) Yes No If yes, please explain: NOTE TO RHODE ISLAND APPLICANTS: This company is subject to the state’s workers’ compensation laws (Chapter 29-38) unless otherwise noted below (employer to list applicable exemptions): Previous EmploymentStarting with your most recent employment, provide the following information.Employer #1(Required) Phone(Required)Address Street Address City State / Province / Region Date Started(Required) MM slash DD slash YYYY Date Ended(Required) MM slash DD slash YYYY Starting Job Title(Required) Ending Job Title(Required) Most recent supervisor name and title(Required) Email May we contact for reference?(Required) Yes No Reason for leaving:(Required) Summarize the type of work performed and job responsibilities:(Required) What did you like most about your position?(Required) What were the things you liked least about the position?(Required) Employer #2 PhoneAddress Street Address City State / Province / Region Date Started MM slash DD slash YYYY Date Ended MM slash DD slash YYYY Starting Job Title Ending Job Title Most recent supervisor name and title Email May we contact for reference? Yes No Reason for leaving: Summarize the type of work performed and job responsibilities: What did you like most about your position? What were the things you liked least about the position? Employer #3 PhoneAddress Street Address City State / Province / Region Date Started MM slash DD slash YYYY Date Ended MM slash DD slash YYYY Starting Job Title Ending Job Title Most recent supervisor name and title Email May we contact for reference? Yes No Reason for leaving: Summarize the type of work performed and job responsibilities: What did you like most about your position? What were the things you liked least about the position? Please explain any gaps in your employment, other than those due to personal illness, injury, or disabilityIf not addressed on previous section, have you ever been fired or asked to resign from a job? Yes No If yes, please explain SkillsSummarize any special training, skills, languages, licenses, and/or certificates that may assist you in performing the position for which you are applying:(Required)Computer Skills(Required) Word Processing Spreadsheet Presentation Internet Computer Skills DetailPlease list all other computer skills and proficiency. Include software titles and level of experience, such as basic, intermediate, or advanced.When answering these questions, please exclude any information that would reveal sex (including pregnancy, sexual orientation and gender identity), race, color, religion, national origin, citizenship, age, disability, genetic information, or other similarly protected status.To what job-related organizations (professional, trade, etc.) do you belong? List special accomplishments, publications, awards, etc.List any relevant volunteer work.Please tell us other job-related information you want us to know about you Educational BackgroundStarting with your most recent school attended, provide the following information.School Name #1(Required)Include City and State Completed:(Required) Diploma GED Certification Degree Other #1(Required)# of years completedGPA Class RankMajor/Minor Add RemoveSchool Name #2Include City and State Completed: Diploma GED Certification Degree Other #2# of years completedGPA Class RankMajor/Minor Add RemoveSchool Name #3Include City and State Completed: Diploma GED Certification Degree Other #3# of years completedGPA Class RankMajor/Minor Add RemoveSchool Name #4Include City and State Completed: Diploma GED Certification Degree Other #4# of years completedGPA Class RankMajor/Minor Add RemoveReferencesList names and telephone numbers of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you.Reference #1(Required)NameTitleRelation Add Remove#1(Required)PhoneEmail# of years known Add RemoveReference #2NameTitleRelation Add Remove#2PhoneEmail# of years known Add RemoveReference #3NameTitleRelation Add Remove#3PhoneEmail# of years known Add Remove Applicant StatementI certify that all information I have provided in order to apply for and secure work with this employer is true, complete, and correct. I expressly authorize, without reservation, the employer, its representatives, employees, or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities, and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume, or job interview. I hereby waive any a nd all rights and claims I may have regarding the employer, its agents, employees, or representatives, for seeking, gathering, and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations, or organizations for furnishing such information about me. I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state, or federal law. I understand that this application remains current for only 60 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application. If I am hired, I understand that l am free to resign at any time, with or without cause and wit h or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary a nd that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer’s president. I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an 1-9 Form in this regard. I understand that reasonable safeguards will be taken to protect all personal information provided or obtained in conjunction with this application for employment. My personal information may be shared with the employer’s affiliate(s) a nd third parties engaged by the employer to perform services for the employer. Any personal information shared with an affiliate or third party is to be used solely to perform the services requested by the employer. This Company does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding an applicant from consideration for employment on the basis of his or her sex (including pregnancy, sexual orientation and gender identity), race, color, religion, national origin, citizenship, age, disability, genetic information, or any other protected status under applicable federal, state, or local law. Mandatory Employer Disclosures Not ice to Illinois applicants: Please be advised pursuant to Illinois law, applicants are not obligated to disclose expunged juvenile records of adjudication, arrest, or conviction. Notice to Indiana applicants: This company complies with Indiana law prohibiting smoking in enclosed areas with in places of employment. Notice to Maryland applicants: UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A LIE DETECTOR OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $IOO. Notice to Massachusetts applicants: It is unlawful in Massachusetts 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. Notice to North Dakota applicants: This company complies with North Dakota law prohibiting smoking with in 20 feet of entrance and inside places of employment. Notice to Rhode Island applicants: This company complies with Rhode Island law prohibiting smoking in enclosed areas within places of employment. I understand that any information provided by me that is found to be false, incomplete, or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer’s service, whenever it is discovered.DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT(Required) I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.
