Application for EmploymentPlease Print

Equal access to programs, services and em ployme nt is available to all person s. Those applicants requiring reasonableaccommodation to the application and/or interview process should notify a representative of the Huma n Resources Department.

Firstlast

Name ---;::;- --;:::;- --;;= Applicant ID # _

ZIP CodeStateStreetAddress--- - - --c.:c::;-- - - - --- - - - - - - - - - - -=,----- - - - - - - ---"=-- - - - ---,,,= ,-----

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//___ _ _ _ ____________ _____ Date of app licat ion _ _ L-_ _ L-__Position (s) applied for

Referral So u rce (Please check the appropriate category and list the source.)

o Walk-In _

o Employee _

o Advertiseme nt _

o Co mpany's Website _

o Other Intern et _

o School _

o Job Fair _

o Staffing Agency _

o GovernmentEmployment Agency _

o Other _

AMIf necessary. best time to call you is PM

o Home 0 Cellular /Othe r

May we contact you at work? 0 Yes 0 No

If yes, work num ber and best time to call:

Will you work overtime if required ? 0 Yes 0 No

If no, please explain : _

AMPM

If you are under 18 and it is required,can you furn ish a work perm it? 0 Yes 0 No

If no, please explain: _

Have you submitted an application here before? 0 Yes 0 No

If yes, give da tefs ) and pos itionfs] : _

Have you ever been employed here before ? 0 Yes 0 No

If yes , give dates: From / / To / /

Is thi s applicat ion a request for reemploymentfollowing an extended milit ary leave of abse ncefrom this company? 0 Yes 0 No

Are you legally eligible for employmentin this country? 0 Yes 0 No

Dat e available for work / /

What is you r desired salary ran ge or hourly rate of pay?

$ Per _

Type of employment desired : 0 Full-T ime 0 Part-Time

o Educational Co -O p 0 Seaso nal 0 Tem porary

Will you relocate if job requires it? 0 Yes 0 No

Will you tr avel if job requires it? 0 Yes 0 No

If they have been explained to you , are you able to meet the

attendance requi rements of the po sition ? ... ON/A 0 Yes 0 No

Are you able to pe rform the "essential functio ns" of the jobfor which you are applying (with or without reasonableaccom mo dat ion)?

This question is not designed to elicit information about an applicant's disability.Please do not provide information about the existence of a disability, particularaccommodation, or whethe r accommodation is necessary. These issues may beaddressed at a later stage to the extent permitted by law.

o Yes 0 No 0 Need more information about thejob's"essential functions" to respond

Dri ver 's license number requi red if driving may be required in thejob for which you are applying:

State _

Have you ever been bonde d? 0 Yes 0 No

Answering "yes" to the following question does not constitute an automatic bar toemployment. Factors such as date of the offense, seriousness and nature of theviolation, rehabilitation and position applied for will be taken into account.

Have you ever pleaded "guilty" or "no contest" toor been convicted of a crime? 0 Yes 0 No

If yes , please provid e date(s ) and details: _

Have you entered into an agreement with any forme r emp loyer or

other par ty (such as a non competition agreement) that might, in anyway, restrict your ability to work for our company? 0 Yes 0 No

If yes, please exp lain: _

AN EQUAL OPPORTUNITY EMPLOYER

Employment HistoryStartingwith your most recent employer. provide the following information.Employer Telephone •

.~.

I '~.r

_.I ,...

( ) Dates employed: to

Street address City Stat e

o Hourly o Sa14ry I $ perStarting job title/fina l jo b title

Commissionj BonusjOthtr Compconsa tion $lm~iate wperv;sor and title (for Il105t recent position held) May wt CORtAct for ml'rence?

D VM ON<> Outer o Hourty D ,,"~ I $Wily dld )'OIl ltaW'?

per

E-mail: Commission/Bonus/Other Compensation $Summarize tht typt! of work performed andJob resporuibitities.

What did you like most about your position?

Wh.t welt the things you Ii~ lust about the position?

Employer Tf'tephone •_.

I 'N'_.

I -I ) DatM employed: to

Street addrns (ity State

o Hourty o Salary I $ perStarti ng job tit le/final job title

Commission/Bonus/OttlE-r Compensation $

Immediate supervisor and title (for most teceet position held) May wt' contact for ", fefence?

DVM ON<> O uter o Hourty D ,,"~ I $ ""Why did you luve?

E-mail: ( omm;nion/ BonusjOtl\eor Compensatio n $

Summarize the type of war. performed and Job respon~lblh tle~.

What did you like most about your position?

What were the things you liked least about the position ?

Em""'" Teleptlone I_.

I ~.

_.I ~.

( \ Dates employed: te

Street addl'flS City Sta te

D Hourly D Salary I $ pO'Starting jo b t ille/ final job title

(ommission/Bonu~/Dthe' (o mpensetion $

Immediate ~UperviSOI and title (fol most recent positio n held) Maywe contact for leference?

D VM ON<> O u ter D Kourly D ,,"~ 1 $ p"Whydid you le.rve?

E-mail: Commission/ Bonus/Other Compensation $

Summanze the type of work perlormed and Job responslblhties.

What did you like most about your positio n?

What were the things youliked least about the position?

£m~r Telephone I_.

I~.

_.I ~"

( ) Oates l:'mployed: tc

Street addless City State

D Hourly o Salary I $ pO'Starting job title/final job tit le

Commission/Bonus /Othe l Compensation $

Immediate supervisor and title (for most recent position held) Maywe contact fOI reference?

D VM ON. D ute, D Hourly o Salary I $ "".Why did you lu ve?

I-mail: Commission/Bonus/Other Compensation $

What did you like most about your position?

What wefe the th ings you liked least about the position?

Employment History {ccnt inued]

Explain any gaps in your employment, other than those due to personal illness, injury or disability. _

If not add ressed on previous page, have you ever been fired or asked to resign from a job? 0 Yes 0 No

If yes, please explain: _

Skills and QualificationsSummarize any special training. skills, licenses and/orcertificates that mayassist you in performing the position for which you are applying:

Co mputer Ski lls (Check appropriate boxes. Include software titles and years of experience.)

o Word Processing Years: o Int ernet Years:

o Spreadsheet Years: O Other Years:

o Presentatio n Years: OOther Years:

D E-mail Years: OOther Years:

Educational BackgroundStarting with your most recent school attended, provide the following information.-~~~~~--~._.~ TS~~~__~__~~'_ ~~,.~n·l·~ :;---.;" "(~1 .. Years rr~t..·· ~ ...w'>'C;~· ...· -, ,. J,~ h"~I'- GPA "'-'·~~ ".

School (include City andState) i1l.:.ill~r:~..~.;'::";' _~~~f~," L;~com leted -l;;..\;;;~.~2'!1 p teted ~.,:~ ..""d'~ (~~5S Ra ~'k J..~ajor/~i~o~~,L.

o Diplom.a OGED

D"'~OCertification

DOtho'OOiptoma DGED

D"'~o CertifiutionD_O Diploma O GED

D"'~o (ertifiCOItion

D Ottier

D DiplomOl D GEDD Degreeo CertificationDOt her

ReferencesList names and telephone numbers o f three business/wo rk references who are not related to you and are not previous supervisors.If not applicable, list three schoo l or person al references who are not related to you.

)

Social Security NumberSS# _

We will use this information only for employment purposes and make reasonable efforts to safeguard your privacy.

Related InformationTo what job- related organizations (professional. trade, etc.) do you belong?

Exclude memberships that would reveal race. color. religion . sex, national origin , genetic information. citizenship, age, mental or physical disabilities.veteran/reserve. National Guard or any other similarly protected status.

Organization Offices Held

List special accomplishm ents. publicat ions, awards, etc.Exclude information that would reveal race. color, religion, sex, national origin, genetic information, citizenship, age, mental or physical disabilities.veteran/reserve, National Guard or any other similarly protected status.

In your current or a previous job. have you ever written inst ructions or directions to be followed by employees or customers?

D Yes 0 No 0 Not Applicable

If yes, please explain : _

Is there any other job-related informa tion you want us to know about you?

Applicant Statement

I cert ify that all informa tion 1haw provided in ord er to apply for and secu re .....or k with this employer is true. com plete and correc t.

I expressly authorize. without reservation. the employer. its representatives. employees or agen ts to contact and obtai n info rmation from all references (personal and professional) .employers. pub lic agencies. licensing aut horities and educational institutions and to otherwise verify the accuracy of all information provided by me in this applicatio n, resume orjob interview. I he reby waive any and all rights and claims I may have regarding the employer. its agents . employees or representatives. for seeking . gathe ring and using truthful andnon -defamatory information, in a lawful manner, in the employment process and all othe r persons. corpo rations or organizations for furnishing such information about me.

I understand that this employe r does no t unlawfully disc rimi nate in employment and no question on this application is used for the purpose of limiting or eliminating any applicantfrom consideration for employment on any basis prohibited by applicable local, state or federalla....'.

1understand that this application remai ns cu rrent for only 30 days . At the conclusion of that time, if I have not heard from the em ployer and st ill wish to be considered foremployment, it wiIl be necessar y for me to reapply and fill out a new appl ication.

If I am hired, I understand that I am free to resign at any tim e, with or without cause and with or without pr ior notice. and the-em ployer reserves the same right to termi nate myemployment at any time. with o r without cause and with or withou t pr ior notice. except as may be requ ired by law. Th is application does not cons titute an agreement o r con trac t forem ployment for any specified pe riod or de-finite du rat ion . 1unde- rstand th at no supervisor or repr esentative of the employe r is author ized to make any assu rances to the con traryand that no imp lied oral or writt en agreemen ts contrary to the fo regoing express language are valid unless they are in writ ing and signed by the employer 's preside nt.

I also understand that if I am hired , I will be required to provide proof of identity and legal authorizat ion to work in the United States and that federal imm igrat ion laws requ ire meto com plete an 1-9 Form in this regard .

This Company docs not tolerate un lawful discrimination in it s employment practices. No qu estion on this application is used for the purpose of limiting or exd ud ing anapplica nt from considera tion for employment on the basis of his or her sex, ra ce, color. religion, national origin, gen ett c info rmation, citizenship, age, disability, or an yother pr otected status under applicable federal. state, o r locallaw, Thi s Co mpa ny likewise du es not tolerate harassment based on sex, race, co lor, reli gion . nation al o rig in,citize nship. genetic information, age, disability, or an y other pr otected status. Exam ples of prohibited hara ssment include, but are not limited to. unwelcome physicalcontac t , offensive ges tures. unwelcome com ments, jok es. epithets. threat s, insults. nam e-calling, negativ e stereotyping . possession o r d isplay of derogatory pictures o rother graphi c m ateri als . and an)' other words o r cond uct th at dem ea n, stigmatize, intimidate. o r single out a person becau se ofhiilher member shi p in a protected category.Har assment of o ur em ployees is stri' tly prohibited . whether it is comm itted by a manager, cowor ker. subo rd ina te. o r non -employee {such as a vend or o r customer).The Company ta kes all com plaints of harassment ser io usly an d all co mplai n ts will be investigated pr omptly a nd th o ro ug hly

I understand that any information provided by me that is found to be false . incomplete or misrepresented in any respect . wilt be sufficient cause to (i) eliminate mefrom further consideration for employment . or (ii ) may result in my immediate discharge from the employer's service. whenever it is dtsccvered.

DO NOT SIGN UNTIL YOU HAVE READ TH E ABOVE APPLICANT STATEMENT.

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

IISignature of App licant Date __-'-__1-_ _

800·<)99-9111 • www.gneil.com to reorder

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C20 t l EDl Important note: This ts al'prnved for use by the purchaser only. This form may nol ~ .h ared publicly or with third parties

Application for Employment (Long Forrn) .R I-A216J_ENG