2015 Application Online Application -2015 Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/ or interview process should notify a representative of the Human Resources Department. Name* First Middle Last Applicant ID#Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Telephone*Cellular/ Other Phone #Email Address Position(s) Applied For*Date of Application* Referral Source Category* Walk-in Employee Advertisement Company’s Website Other Internet School Job Fair Staffing Agency Government Employment Agency Please Check the Appropriate Referral Category Refferal SourcePlease List the Source that Accompanies the Category Chosen AboveIf necessary, best time to call you is…*Best number to contact you is…* Home Cellular / Other May we contact you at work?* Yes No If YES, please list work number and best time to callIf you are under 18 and it is required, can you furnish a work permit? Yes No If NO, please explain:Have you submitted an application here before?* Yes No If YES, give date(s) and position(s):Have you every been employed here before?* Yes No Is YES, give dates:From mm/dd/yyyy – To mm/dd/yyyyIs this applications a request for reemployment following an extended military leave of absence from this company?* Yes No If YES, additional information may be requested. Are you legally eligible for employement in this country?* Yes No Date available for work…* What is your desired salary range or hours rate of pay?*$$____________ PER_____________Type of employement desired:* Full Time Part Time Educational Co-OP Seasonal Temporary Will you relocate if job requires it?* Yes No Will you travel if job requires it?* Yes No If they have been explained to you, are you able to meet the attendance requirements of the position?* N/A Yes No Will you work overtime if 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)?* Yes No Need more information about the job’s “essential functions” to respond 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. Driver's license number required if driving may be required in the job for which you are applying:License # and State Have you ever been bonded?* Yes No Have you ever pleaded "guilty" or "no contest" to or been convicted of a crime?* Yes No Answering “yes” to this question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account. If YES, please provide date(s) and details: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?* Yes No If YES, please explain:Employment HistoryStarting with your most recent employer, provide the following information. Current or most recent employerEmployer*Telephone*Dates employed:*Month/Year – Month/YearAddress* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Starting job title / final job title* Compensation Starting Pay Type* Hourly Sallery Rate*$$__________ Per__________Commision / Bonus/ Other Compensation* Compensation Final Pay Type* Hourly Sallery Rate*$$__________ Per__________Commision / Bonus/ Other Compensation*Immediate supervisor and title (for most recent position held)*May we contact for reference?* Yes No Later Email Why did you leave?*Summarize the type of work performed and job responsibilities.*What did you like most about your position?*What were the things you liked least about the position?*Next Previous EmployerEmployerTelephoneDates employed:Month/Year – Month/YearAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Starting job title / final job title Compensation Starting Pay Type Hourly Sallery Rate$$__________ Per__________Commision / Bonus/ Other Compensation Compensation Final Pay Type Hourly Sallery Rate$$__________ Per__________Commision / Bonus/ Other CompensationImmediate supervisor and title (for most recent position held)May we contact for reference? Yes No Later Email Why did you leave?Summarize the type of work performed and job responsibilities.What did you like most about your position?What were the things you liked least about the position?Next Previous EmployerEmployerTelephoneDates employed:Month/Year – Month/YearAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Starting job title / final job title Compensation Starting Pay Type Hourly Sallery Rate$$__________ Per__________Commision / Bonus/ Other Compensation Compensation Final Pay Type Hourly Sallery Rate$$__________ Per__________Commision / Bonus/ Other CompensationImmediate supervisor and title (for most recent position held)May we contact for reference? Yes No Later Email Why did you leave?Summarize the type of work performed and job responsibilities.What did you like most about your position?What were the things you liked least about the position?Next Previous EmployerEmployerTelephoneDates employed:Month/Year – Month/YearAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Starting job title / final job title Compensation Starting Pay Type Hourly Sallery Rate$$__________ Per__________Commision / Bonus/ Other Compensation Compensation Final Pay Type Hourly Sallery Rate$$__________ Per__________Commision / Bonus/ Other CompensationImmediate supervisor and title (for most recent position held)May we contact for reference? Yes No Later Email Why did you leave?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?Explain any gaps in your employment, other than those due to personal illness, injury or disability.If not addressed on previous page, have you ever been fired or asked to resign from a job?* Yes No If YES, please explain:Skills and QualificationsSummarize any special training, skills, licenses and/or certificates that may assist you in performaning the position for which you are applying:*Computer Skills* Word Processing Spreadsheet Presentation E-mail Internet Check appropriate boxes. Software Skills*List the software titles and years of experience for the Computer Skills selected abovePlease list any other computer skills not listed aboveBe sure to include software titles and years of experienceEducational BackgroundStarting with your most recent school attended, provide the following information. Most Recent School AttendedSchool*include City and State Years Completed*Completed* Diploma GED Degree Certification Other Please list Degree/ Certification/ Other if Chosen AboveGPA Class Rank*Major/ Minor Next Recent School AttendedSchoolinclude City and State Years CompletedCompleted Diploma GED Degree Certification Other Please list Degree/ Certification/ Other if Chosen AboveGPA Class RankMajor/ Minor Next Recent School AttendedSchoolinclude City and State Years CompletedCompleted Diploma GED Degree Certification Other Please list Degree/ Certification/ Other if Chosen AboveGPA Class RankMajor/ Minor Next Recent School AttendedSchoolinclude City and State Years CompletedCompleted Diploma GED Degree Certification Other Please list Degree/ Certification/ Other if Chosen AboveGPA Class RankMajor/ MinorReferencesList 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 Number One Name* First Last TitleRelationship to You*Telephone*Email # of Years Known* Reference Number Two Name* First Last TitleRelationship to You*Telephone*Email # of Years Known* Reference Number Three Name* First Last TitleRelationship to You*Telephone*Email # of Years Known*Related InformationTo what job-related organizations (professional, trade, etc.) do you belong?Please list the Organization and Offices Help. 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. List special accomplishments, publication, awards, etc.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. In your current or a previous job, have you ever written instructions or directions to be followed by employees or customers?* Yes No Not Applicable If YES, please explain:Is there any other job-related informaiton you want us to know about you?Applicant StatementI certify that all information I have provided in order to apply for an 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 (person 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 and 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 30 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 I am free to resign at any time, with or without cause and with 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 and that no implied oral or written agreements contrary to the forgoing express language are valid unless they are in writing and signed but 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 I-9 Form in this regard. 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, race, color, religion, national origin, genetic information, citizenship, age, disability, or any other protected status under applicable federal, state or local law. This Company likewise does not tolerate harassment based on sex, race, color, religion, national origin, citizenship, genetic information, age, disability, or an other protected status. Examples of prohibited harassment include, but are not limited to unwelcome physical contact, offensive gestures, unwelcome comments, jokes, epithets, threats, insults, name -calling, negative stereotyping, possession or display of derogatory pictures or other graphic materials, and any other words or conduct that demean stigmatize, intimidate, or single out a person becasue of his/her membership in a protected category. Harassment of our employees is strictly prohibited, whether it is committed by a manager, coworker, subordinate, or non-employee (such as a vendor or customer). The Company takes all complaints of harassment seriously and all complaints will be investigated promptly and thoroughly. 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 CHECK UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT* I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement. If you have any further documents, such as a resume to include, please upload here. Drop files here or Select files Accepted file types: jpg, gif, png, pdf, doc, docx, zip, Max. file size: 2 GB. CAPTCHA