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8/10/2019 2014-Application for Employment
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Employment Application
Applicant Information
Full Name:Last First M.I. Date:
Address:Street Address Apartment/Unit #
City State ZIP Code Social Security No
Phone: Email:
Years Experiences: Date Available: Desired Salary: $
Are you at least 18?
YES NO
Are you a citizen of the United States?
YES NO
If no, are you authorized to work in the
YES NO
Have you ever worked for this companyYES NO
If yes, when
Have you ever been convicted of a felony?
YES NO
If yes, explain
Education
High School: Address:
From: o:
Did you
graduate?
YES NO
Diploma:
College: Address:
Position Applied:
Referred By:
Wright Gregory J Aug 10, 1987
5305 Poplar Valley Ct
Centreville VA 20772 220-19-0864
240-398-6472 [email protected]
Apprentice
0 ASAP 17
Frederick Douglass 3330 Croom Road
2001 2005
Frostburg Cumberland , Md
8/10/2019 2014-Application for Employment
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Employment Application
General Information
Are you a Certified Journeyman? YES No
Special Training or Certification:
Subject Of Special Study or Research:
Military Service: YES No Rank at Discharge:
Type of Discharge:
If other than honorable, explain:
Do you understand you are required to provide tools in compliance with the company tool list and job
requirements?
YES No
Do you understand that you must provide your own transportation to jobsite? Jobsites are in Northern VA, DC,
MD, WV
YES No
Are you willing to work alternative shifts?YES No
Are you willing to work overtime?YES No
Have you supervised others before? How many? YES No
Do you understand the ability to work well with your co-workers is a job requirement throughout your
employment?
YES No
Do you understand that you are expected to work equally well with people of other races, ethnic groups,
religious or gender?
YES No
Do you have a valid driver license? YES No
Do you have a good driving record?YES No
Do you understand that you are required to follow OSHA Safety practice without fail?
YES No
8
8/10/2019 2014-Application for Employment
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Employment Application
Previous EmploymentStart with most recent employer
Company: Phone:
Address: Supervisor:
Job Title: Starting Salary:$ Ending Salary:$
Responsibilities:
From: To: Reason for Leaving
May we contact your previous supervisor for a reference?
YES NO
Company: Phone:
Address: Supervisor:
Job Title: Starting Salary:$ Ending Salary:$
Responsibilities:
From: To: Reason for Leaving
May we contact your previous supervisor for a reference?
YES NO
Company: Phone:
Address: Supervisor:
Job Title: Starting Salary: $ Ending Salary: $
Your Health Magazine 336-392-9945
1330 little river turnpike Annandale, VA Sarah
Account manager 12
customer service, cold calling, sales
12
1-2014 3-2014 Moved away
Muddy Mutt 703-580-4499
2234 South Oxford st Arlington, Va Andrew Lowe
Manager 12 12
Cleaning, Cashier, Customer Service,
8-2013 1-2014 Moved away to centreville
8/10/2019 2014-Application for Employment
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Employment Application
ReferencesPlease list three references
Full Name: Relationship:
Company: Phone:
Address: Years Known:
Full Name: Relationship:
Company: Phone:
Address: Years Known:
Full Name: Relationship:
Company: Phone:
Address: Years Known:
Disclaimer and Signature
I hereby authorize the potential employer to contact, obtain, and verify the accuracy of information contained in this
application from all previous employers, educational institutions, and references. I also hereby release from liability thepotential employer and its representatives for seeking, gathering, and using such information to make employment decisions
and all other persons or organizations for providing such information.
I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for
cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered.
This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by American
with Disabilities Act (ADA) and other relevant federal and state laws.
If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute
an agreement or contract for employment. Accordingly, either I or the employer can terminate the relationship at will, with or
without cause, at any time, so long as there is no violation of applicable federal or state law.
We are an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to
race, color, religion, gender, sexual orientation, national origin, citizenship, age, height, weight, or disability. We assure you that
Leila Rashidi friend
Law office of Brian Murry 703-203-4304
2
Renee Shamberger co-worker
Muddy Mutt 301-526-3249
7+
Shaynah Williams co workerMuddy Mutt 202-569-0277
7+
8/10/2019 2014-Application for Employment
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Equal Employment Opportunity Commission
Voluntary Questionnaire
The Equal Employment Opportunity Commission (EEOC) requires organizations with 100 or more employeesto complete an EEO-1 report each year. Completion of this ata is !oluntary an will not affect your
opportunity for employment or terms or conitions of employment. This form will "e use for EEO-1 reportingpurposes only an will "e #ept separate from all other personnel recors only accesse "y $uman %esources&epartment. 'lease return complete forms to the $uman %esources &epartment.
Name
Job Title
GENDER:
('lease chec# one of the options "elow) *ale +emale
RACE/ETHNICITY:('lease chec# one of the escriptions "elow corresponing to the ethnic group with which you ientify.)
Hispanic or Latino, person of Cu"an *eican 'uerto %ican /outh or Central ,merican or other/panish culture or origin regarless of race.
White Not Hispanic or Latino!, person ha!ing origins in any of the original peoples of Europe the*ile East or orth ,frica.
"lac# or A$rican American Not Hispanic or Latino!, person ha!ing origins in any of the "lac# racialgroups of ,frica.
Nati%e Ha&aiian or 'ther (aci$ic Islan)er Not Hispanic or Latino!, person ha!ing origins in anyof the peoples of $awaii uam /amoa or other 'acific 2slans.
Asian Not Hispanic or Latino!, person ha!ing origins in any of the original peoples of the +ar East/outheast ,sia or the 2nian /u"continent incluing for eample Cam"oia China 2nia 3apan 4orea*alaysia 'a#istan the 'hilippine 2slans Thailan an 5ietnam.
American In)ian or Alas#a Nati%e Not Hispanic or Latino!, person ha!ing origins in any of the
original peoples of orth an /outh ,merica (incluing Central ,merica) an who maintain tri"al affiliation orcommunity attachment.
T&o or *ore Races Not Hispanic or Latino!,ll persons who ientify with more than one of thea"o!e fi!e races.
Date complete)
Greg Wright
Apprentice
3-19-2014
8/10/2019 2014-Application for Employment
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8/10/2019 2014-Application for Employment
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Este empleador le proporcionar a la Administracin del Seguro
Social (SSA), y si es necesario, al Departamento de Seguridad
Nacional (DHS), informacin obtenida
del Formulario I-9 correspondiente a
cada empleado recin contratado con el
propsito de confirmar la autorizacin de
trabajo.
IMPORTANTE: En dado caso que el gobierno
no pueda confirmar si est usted autorizado
para trabajar, este empleador est obligado
a proporcionarle las instrucciones por escrito
y darle la oportunidad a que se ponga en
contacto con la oficina del SSA y, o el DHS
antes de tomar una determinacin adversa
en contra suya, inclusive despedirlo.
restringir o influenciar la seleccin de los documentos que sean
presentados para ser utilizados en el Formulario I-9.
A fin de poder determinar si la
documentacin del Formulario I-9 es
valida o no, este empleador utiliza la
herramienta de seleccin fotogrfica de
E-Verify para comparar la fotografa que
aparece en algunas de las tarjetas de
residente y autorizaciones de empleo, con
las fotografas oficiales del Servicio de
Inmigracin y Ciudadana de los Estados
Unidos (USCIS).
Si usted cree que su empleador ha violado
sus responsabilidades bajo este programa,
A V I S O:
La Ley Federal le exige a
todos los empleadores
que verifiquen la identidad y
elegibilidad de empleode toda persona contratada
para trabajar en
los Estados Unidos.
Participa en E-Verify
Este Empleador
8/10/2019 2014-Application for Employment
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IF YOU HAVE THE RIGHT TO WORK,
Dont let anyone take it away.
If you have a legal right towork in the United States,
there are laws to protectyou against discriminationin the workplace.
You should know that
No employer can deny youa job or re you becauseof your national origin orcitizenship status.
In most cases employerscannot require you to be aU.S. citizen or permanentresident or refuse anylegally acceptabledocuments.
If any of these things havehappened to you, you may
have a valid charge ofdiscrimination that can beled with the OSC. Contactthe OSC for assistance inyour own language.
Call 1-800-255-7688. TDDfor the hearing impaired is
1-800-237-2515.
In the Washington, D.C.,area, please call202-616-5594, TDD202-616-5525
Or write to:U.S. Department of JusticeOffice of Special Counsel - NYA950 Pennsylvania Ave., N.W.Washington, DC 20530
U.S. Department of JusticeCivil Rights Division
Office of Special Counsel forImmigration-Related UnfairEmployment Practices
8/10/2019 2014-Application for Employment
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SI USTED TIENE DERECHO A TRABAJAR,
no deje que nadie se lo quite.
Si tiene derecho a trabajarlegalmente en los Estados
Unidos, existen leyespara protegerlo contrala discriminacin en eltrabajo.
Debe saber que -
Ningn patrn puedenegarle trabajo, ni puededespedirlo, debido a su pasde origen o su condicin deinmigrante.
En la mayora de los casos,los patrones no puedenexigir que usted seaciudadano de los EstadosUnidos o residente permanente o negarse a aceptardocumentos validos por ley.
Si se ha encontrado encualquiera de estas
situaciones, usted podratener una queja valida dediscriminacin.Comunquese con la Ocinadel Consejero Especial (OSC)de Practicas Injustas en elEmpleo Relacionadas a laCondicin de Inmigrantepara obtener ayuda enespaol.
Llame al 1-800-255-7688; TDDpara personas con problemas
de audicin: 1-800-237-2515.En Washington, DC, llame al(202) 616-5594: TDD parapersonas con problemas deaudicin: (202) 616-5525. Oescrbale a OSC a lasiguiente direccin:
U.S. Department of JusticeOffice of Special Counsel - NYA950 Pennsylvania Ave., N.W.Washington, DC 20530
Departamento de Justiciade los Estados Unidos,
Divisin de DerechosCiviles
Oficina del Consejero Especial