RECORD OF PREVIOUS EMPLOYMENT
Please list the names of your present or previous employers in chronological order with present or last employer listed first. Be sure to account for all periods of time including any period of unemployment. If self-employed, give firm name and supply business references. [Add additional page if necessary]
THIS APPLICATION WILL BE CONSIDERED ACTIVE FOR A MAXIMUM OF THIRTY (30) DAYS. IF YOU WISH TO BE CONSIDERED FOR EMPLOYMENT AFTER THAT TIME, YOU MUST REAPPLY.
I CERTIFY THAT ALL OF THE INFORMATION THAT I HAVE PROVIDED ON THIS APPLICATION IS TRUE AND ACCURATE.
APPLICANT'S STATEMENT & AGREEMENT
1. I understand that the Company may require me to submit to a test for the presence of drugs in my system prior to employment and at any time during my employment, to the extent permitted by law. I also understand that any offer of employment may be contingent upon the passing of a physical examination. I understand that bonding may be a condition of hire. If it is, I will be so advised either before or after hiring and a bond application will have to be completed.
2. I hereby certify that all the information that I have provided on this application is true and accurate to the best of my knowledge. I understand that any misrepresentation, falsification, or material omission of information on this application may result in my failure to receive an offer or, if I am hired, my immediate dismissal from employment. I authorize the Company the right to contact and obtain information from all references, employers, and educational institutions in order to verify the accuracy of the information contained in this application. I also authorize the references, employers, and educational institutions whom the Company contacts, to verify the accuracy of the information contained in this application. Further, I hereby release from liability the Company and its representatives for seeking, gathering and using such information and all other persons, corporations or organizations for furnishing some information, except as precluded by applicable law.
3. I understand that any offer of employment is conditioned upon proof of identify and proof of legal authority to work in the United States.
4. I understand that the Company does not discriminate in employment on any unlawful basis, and that if needed due to a disability, reasonable accommodations will be provided during the application process in the manner and to the extent necessary to allow me to participate fully. I also understand that if hired, reasonable accommodations will be provided if reasonable accommodations are available and will allow me to perform the essential functions of the job, and will not impose an undue hardship on the Company. I further understand that no question on this application has been asked for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable law.
5. I agree that, if hired, my employment shall not be for any specific duration and either the Company or I may terminate my employment relationship at any time, with or without cause and/or with or without prior notice. This express at-will acknowledgement supersedes any and all prior representations or understandings, whether written or oral, express or implied, between the Company and me. I understand that no one other than the HR Director of the Company may enter into an agreement for any specified period of time, or to make any agreement contrary to the foregoing. Further any such agreement must be in writing signed by you (or your representative) and the HR Director of the Company. I understand that this constitutes an integrated agreement with respect to the at-will nature of my employment relationship, that is final and fully binding, and that there are no oral, written, or collateral agreements regarding this issue.
6. If any term or provision, or portion of this Agreement is declared void or unenforceable it shall be severed and the remainder of this Agreement shall be enforceable.
7.Any modification of this Agreement must be in writing and signed by you (or your representative) and the HR Director for the Company.
DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE STATEMENT & AGREEMENT. IF YOU HAVE ANY QUESTIONS REGARDING THIS STATEMENT, PLEASE ASK A COMPANY REPRESENTATIVE BEFORE SIGNING.
I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE STATEMENTS AND UNDERSTAND AND AGREE TO THE SAME.
EQUAL EMPLOYMENT OPPORTUNITY DATA
This employer is subject to certain governmental record keeping and reporting requirements for the administration of civil rights laws and regulations. Completion of this form is entirely VOLUNTARY. YOU DO NOT HAVE TO PROVIDE THE INFORMATION BELOW. All information will remain confidential and will not affect your application for employment or subject you to any adverse treatment. It will not become part of your personnel record if you are hired by this company and will only be used as required by law. When reported, data will not identify any specific individual.
Male Female Prefer not to answer
Race/Ethnicity (Definitions are on the next page as provided by the federal Equal Employment Opportunity Commission):
American Indian or Alaskan Native Asian Black or African-American Hispanic or Latino White (Not Hispanic or Latino) Native Hawaiian or other Pacific Islander Two or More Races Prefer not to answer
Definitions of the EEO-1 race and ethnicity categories are as follows:
Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East or North Africa.
Black or African-American (Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa or other Pacific Islands.
Asian (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.
Native American or Alaska Native (Not Hispanic or Latino) - A person having origins in any of the original people of North and South America (including Central America), and who maintain tribal affiliation or community attachment.
Two or More Races (Not Hispanic or Latino) - All persons who identify with more than one of the above five races.
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