Employment Application

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This is a Drug-Free Workplace Offering Equal Employment Opportunities. Applications are received and employees are hired without regard to race, creed, color, sex, religion, age, genetic information, national origin, physical or mental handicap, disability, veteran’s status, citizenship status, or any other protected classes under state, local or county regulations. The receipt of this application does not mean that job openings exist and does not obligate us in any way. We appreciate your interest in our organization.

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Your Personal Information

Name *

Address *

Choose Your State:

Phone *

Preferred method of contact

Employer #1 *

Employer Address *

State:

Dates Employed *

State Reason *

Hourly Rate, Weekly Salary or Other Weekly Earnings *

Summary of Work Performed & Job Responsibilities

Supervisor *

Employer #2

Employer Address

State:

Dates Employed

State Reason

Hourly Rate, Weekly Salary or Other Weekly Earnings

Summary of Work Performed & Job Responsibilities

Supervisor

Employer #3

Employer Address

State:

Dates Employed

State Reason

Hourly Rate, Weekly Salary or Other Weekly Earnings

Summary of Work Performed & Job Responsibilities

Supervisor

Employer #4

Employer Address

State:

Dates Employed

State Reason

Hourly Rate, Weekly Salary or Other Weekly Earnings

Summary of Work Performed & Job Responsibilities

Supervisor

Employer #5

Employer Address

State:

Dates Employed

State Reason

Hourly Rate, Weekly Salary or Other Weekly Earnings

Summary of Work Performed & Job Responsibilities

Supervisor

Employer #6

Employer Address

State:

Dates Employed

State Reason

Hourly Rate, Weekly Salary or Other Weekly Earnings

Summary of Work Performed & Job Responsibilities

Supervisor

Employer #7

Employer Address

State:

Dates Employed

State Reason

Hourly Rate, Weekly Salary or Other Weekly Earnings

Summary of Work Performed & Job Responsibilities

Supervisor

Have you completed an application here before?

Have you been employed here before?

Are you available to work (Check any that apply):

Are there any days or times during the week that you are not available to work?
(Reasonable accommodation of religious needs that do not create an undue hardship will be considered, if applicable)

If yes, please list the days/times you are not available to work:

If necessary, can you provide proof that you are over any minimum work age requirement?

Are you willing to work overtime? Do you have steady transportation to work?

Can you travel, if required? What percentage of time?

Are you on a layoff and subject to recall? May we contact your present employer?

How much time have you lost from work during the past 12 months?

Are you now, or do you expect to be, engaged in any other business or employment while working here?

If yes, please explain

Are you presently an officer, employee, or employer of another business in our industry or with whom we compete?

If yes, please explain

Have you ever been terminated or asked to resign from a job?

If yes, please explain

Why do you desire to make a change

Are you legally eligible to work in the United States?
(Proof of citizenship status/identity required upon hire)

What three things are most important to you in a job?


What three adjectives best describe you?


What type of work do you most enjoy?

Why do you want to work here?

Have you ever been a customer of ours?
If yes, what services did you receive:

List any special skills, training, experience, certifications, or licenses that may be relevant to this position or our company

List any professional, trade, business, or civic activities or offices held that would relate to working here

List any foreign languages that you fluently speak, read, and/or write that would relate to working here

List software programs that you are proficient in

High School or GED

Did you graduate?   Years Completed

Degree received and Major subject

Name of School Location

Trade, Business, or Correspondence

Did you graduate?   Years Completed

Degree received and Major subject

Name of School Location

College

Did you graduate?   Years Completed

Degree received and Major subject

Name of School Location

Graduate School

Did you graduate?   Years Completed

Degree received and Major subject

Name of School Location

Tell Us About Your Driving Record

Necessary for positions that may require use of a personal or company vehicle for work

Do you hold a valid and unexpired Driver’s License that is not currently suspended or revoked?

If yes, provide the state

Have you been convicted of any moving violation(s) in the last 5 years?

If yes, give date(s) and explanation of each

Military Service

Branch of Service

Rank at Discharge (if applicable)

List Duties and Special Training and/or Skills

Non-Compete Agreement

Are you currently subject to a Non-Compete Agreement or Restrictive Covenant that would prohibit you from working at our company in the position for which you are applying?

If yes, provide a copy of the agreement and state the name of the company:

Tell Us About Your Past

Answering “yes” to any of these questions is not an automatic bar to employment.

Have you ever been disciplined or terminated from any job for an act of violence, harassment, discrimination, ethical breach or theft?

If yes, explain the circumstances, employer, and date:

Have you ever been a defendant in a civil action for an intentional tort? (e.g. assault, battery, false imprisonment, infliction of emotional distress, tortuous interference with a business relationship, defamation, invasion of privacy, fraud and misrepresentation, abuse of process and malicious prosecution or others)

If yes, provide an explanation of the nature of the intentional tort, the date of the action, the location, and the disposition or outcome:

Have you ever had any professional license or certificate suspended or revoked (e.g., pest control operator’s license, law license, real estate license, etc.)?

If yes, list the professional license(s) and/or certificate(s) that were suspended or revoked and state when and why the license(s) and/or certificate(s) were suspended or revoked:

Are you currently under investigation or wanted by any law enforcement agency?

If yes, by what law enforcement agency and for what reason?

"Have you ever been convicted of a criminal offense (Felony or Misdemeanor)?

If yes*, describe the details of the conviction/offense, the sentence for the conviction/offense, the date of the conviction/offense (month and year), and your rehabilitation since then:

*California Candidates:

  • Do not disclose convictions that have been sealed, expunged, or statutorily eradicated; or for which you were referred to, and participated in, any pre-trial or post-trial diversion program.
  • Do not disclose misdemeanor convictions for which probation has been successfully completed or discharged.
  • Do not disclose convictions that are more than two years old for marijuana possession, possession of marijuana pipes or paraphernalia, operation of a business that displays or sells marijuana paraphernalia in areas accessible to minors and being under the influence of marijuana.

*Connecticut Candidates:

  • Do not disclose erased records of arrests, criminal charges, or convictions.
  • Applicants with erased criminal records can swear under oath that they have never been arrested.
  • Criminal records eligible for erasure include delinquency determinations, findings as a child in a family with service needs, youthful offender adjudications, dismissed or nolled criminal charges, criminal charges where the accused was found not guilty or received an absolute pardon, and any other conviction where erasure is allowed by law.

*Hawaii Candidates: Do not answer this question.

*Nevada Candidates: List all felony convictions and any misdemeanor convictions that occurred in the past 10 years and that resulted in imprisonment.

*North Dakota Candidates: List felony convictions only.

*Ohio Candidates: Conviction for a minor misdemeanor violation of the Ohio Rev Code Annotated Section §2925.11 does not constitute a criminal record and need not be reported.

*Pennsylvania Candidates: DO NOT ANSWER THIS QUESTION IF you are applying for a position at a company with 10 or more Philadelphia-based employees.

*Utah Candidates: For any convictions, list only felonies.

*Washington State Candidates: List any convictions or terms of imprisonment within the past 10 years only.

Agreement and Release

For the purpose of this agreement and release, the organization that has provided you with this application is referred to as “the company,” “this company,” or “you” in the following paragraphs:

The facts set forth above in my application for employment are true and complete. I understand that false statements or omission of information on this application (even if discovered after employment) or any other employment form may lead to dismissal or denial of employment. You are hereby authorized to make any investigation of my personal history, financial, criminal, credit, and motor vehicle records through any investigative or credit agencies or bureaus of your choice. You are also authorized to administer a personality profile or other pre-employment tests and verify my background. A criminal record or sentence is not an automatic disqualification for employment. I agree to submit to any drug or alcohol testing prior to or after employment, and I agree to submit to a medical evaluation, if required. I consent to the release of any or all medical information or records deemed necessary to determine my capability to perform the essential job functions of the position for which I may hold.

In making this application for employment, I also understand that an investigative consumer report may be made whereby information is obtained through personal interviews with my neighbors, friends, or others with whom I am acquainted. I also acknowledge that the company may conduct a search for information about me that is in the public domain including, but not limited to, information on social networking sites. In exchange for the consideration of my employment application by this company, I hereby release and forever discharge this company (including its directors, officers, employees, and agents) and my past and/or present employers (including their directors, officers, employees, and agents) from any liabilities which may result from an investigation of my past and/or present employment or from the disclosure of such information. I authorize the use of any information in this application to verify my statements, and I authorize past employers, doctors, all references, and any other persons to answer all questions asked concerning my ability, character, reputation, and previous employment record.

I understand that if my application is accepted and if I am hired, that employment with this company at all times i semployment “at will.” It is further understood that this “at will” relationship may not be changed b yany written document, verbal statements, or by conduct unless an authorized executive of this company specifically acknowledges such change. I further understand that my “at will” employment may be terminated at any time by this company or myself and includes no guarantee, contract, or promise of employment for any specific length of time. I understand that the first 90 days of employment is a new-hire introductory period. Submission of this application does not imply that you will be hired.

I have read, understand, and by my signature consent to these statements:

Enter Your Full Name:   

Your Emergency Contact

In Case of an Emergency, I Authorize You to Contact:

  

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