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Equalaccesstoprograms,servicesandemploymentisavailabletoallpersons.Thoseapplicantsrequiringreasonableaccommodationtotheapplicationand/orinterviewprocessshouldnotifyarepresentativeoftheHumanResourcesDepartment.
Position(s)appliedfor:DateofApplication://
Name(last,first,middle):SocialSecurity#:
N/A
Address(street,city,state,zip):
AlternativeMailingAddress:
Telephone:()CellPhone/Other:()Email:
ReferralSource(Howdidyouhearaboutus?):
EmergencyContactName(last,first,middle):Relationship:
Address(street,city,state,zip):
Telephone:()CellPhone/Other:()Email:
Maywecontactincaseofanemergency?YESNO
AdditionalInformation
Whatpositionareyouapplyingfor:
Howdidyoufindoutaboutthisposition?
Ifyouareunder18anditisrequired,canyoufurnishaworkpermit?YESNO
Ifno,pleaseexplain:
Areyouatleast23yearsofage?YESNO
Haveyoueverbeenemployedherebefore?YESNO
Ifyes,pleasegivedates,positions,andreasonforleaving:
Doyouhaveanyrelativesorfriendsworkinghere?YESNO
Ifyes,pleaselist:
Areyoulegallyeligibleforemploymentinthiscountry?YESNO
Dateavailableforwork://Whatisyourdesiredsalaryrange?
Typeofemploymentdesired:Full-TimePart-TimeTemporarySeasonalEducationalCo-Op
HoursRequestedperWeek:0-120-240-360-4850ormore
EstimatedTimesofAvailability:Note:Pleasespecifytimeswhenyouaretypicallyfreetowork,ifyouhaveaprimaryjobWitharotatingschedulepleaseindicatebelowwhichtypeofscheduleyouareheldto.
24/72withdebitpay24/72withoutdebitpay9dayrotationIftheaboveapplies,whatisyourshiftdesignation?
24fixeddaysOther:
Areyouabletoperformtheessentialfunctionsofthejobforwhichyouareapplying(withorwithoutreasonableaccommodation)?Thisquestionisnotdesignedtoelicitinformationaboutanapplicant’sdisability.Pleasedonotprovideinformationabouttheexistenceofadisability,particularaccommodation,orwhetheraccommodationisnecessary.Theseissuesmaybeaddressedatalaterstagetothe extentpermittedbylaw.
YESNONeedMoreinformationaboutthejob’s“essentialfunctions”torespond
Answering“yes”toeitherofthefollowingquestionsdoesnotconstituteanautomaticbartoemployment.Factorssuchasdateoftheoffense,seriousnessandnatureoftheviolation,rehabilitationandpositionappliedforwillbetakenintoaccount.
Haveyoueverpleaded“guilty”or“nocontest”to,orbeenconvictedforacrime,includingDUI/DWIorsimilaroffense,hadanymovingviolations,orhadyourlicenserevokedorsuspended? YES NO
Ifyes,pleaseprovidedate(s)anddetails:
Listallmovingviolations(convictions),accidents,andanysuspensionsorrevocationsofyourlicenseinthelastfiveyears:
HaveyoueverbeenexcludedorareyoucurrentlyexcludedfromparticipatinginanyfederalhealthprogramsuchasMedicareorMedicaid? YES NO
Ifyes,pleaseexplain:
Areyoupresentlyorinthepastbeeninvolvedinlitigationofaformeremployer?YESNO
EmploymentHistory
Startingwithyourmostrecentemployersorvolunteeractivities,providethefollowinginformation.
Employer: / Telephone:() / DatesEmployed(Month/Year):/to/
Address(street,city,state,zip): / Compensation(Starting):$perHourlySalary
Startingjobtitle/finaljobtitle: / Commission/Bonus/OtherCompensation:$
Immediatesupervisorandtitle(formostrecentpositionheld):Maywecontactforreference?YESNOLATER / Compensation(Final):$perHourlySalary
Commission/Bonus/OtherCompensation:$
Whydidyouleave?
Summarizethetypeofworkperformedandjobresponsibilities:
Employer: / Telephone:() / DatesEmployed(Month/Year):/to/
Address(street,city,state,zip): / Compensation(Starting):$perHourlySalary
Startingjobtitle/finaljobtitle: / Commission/Bonus/OtherCompensation:$
Immediatesupervisorandtitle(formostrecentpositionheld):Maywecontactforreference?YESNOLATER / Compensation(Final):$perHourlySalary
Commission/Bonus/OtherCompensation:$
Whydidyouleave?
Summarizethetypeofworkperformedandjobresponsibilities:
Employer: / Telephone:() / DatesEmployed(Month/Year):/to/
Address(street,city,state,zip): / Compensation(Starting):$perHourlySalary
Startingjobtitle/finaljobtitle: / Commission/Bonus/OtherCompensation:$
Immediatesupervisorandtitle(formostrecentpositionheld):Maywecontactforreference?YESNOLATER / Compensation(Final):$perHourlySalary
Commission/Bonus/OtherCompensation:$
Whydidyouleave?
Summarizethetypeofworkperformedandjobresponsibilities:
CertificationInformation
Certification: / Certification#: / ExpirationDate: / CertifyingAgency
CPR
EMT–Basic
EMT-Intermediate
EMT-Paramedic
NationalRegistry
PALS/NALS
ACLS
BTLS/PHTLS
EMD
CDL
DLClass: / DL#: / IssuingState:
EducationalBackground
Startingwithyourmostrecentschoolattended,providethefollowinginformation:
School(includeCityState) / YearsCompleted / Completed / GPA/ClassRank / Major/Minor
DiplomaGEDDegreeCertification
Other:
DiplomaGEDDegreeCertification
Other:
DiplomaGEDDegreeCertification
Other:
References
Listnameandtelephonenumberofthreebusiness/workreferenceswhoarenotrelatedtoyouandarenotprevioussupervisors.Ifapplicable,listthreeschoolorpersonalreferenceswhoarenotrelatedtoyou.
Name / Title / RelationshiptoYou / Telephone / NumberofYearsKnown
ApplicantStatement
IcertifythatallinformationIhaveprovidedinordertoapplyforandsecureworkwiththisemployeristrue,completeandcorrect.
I expressly authorize,without reservation, theemployer, itsrepresentatives,employees oragents to contactand obtain information from all references(personal andprofessional),employers,public agencies,licensingauthorities andeducationalinstitutions andtootherwiseverify theaccuracyofallinformationprovidedbymein thisapplication,resuméorjobinterview.IherebywaiveanyandallrightsandclaimsImayhaveregardingtheemployer,itsagents,employeesorrepresentatives,forseeking,gatheringandusingtruthfulandnon–defamatoryinformation,inalawfulmanner,intheemploymentprocessandallotherpersons,corporationsororganizationsforfurnishingsuchinformationaboutme.
Iunderstandthatthisemployerdoesnotlawfullydiscriminateinemploymentandnoquestionon thisapplicationisusedforpurposeoflimitingoreliminationanyapplicantfromconsiderationfor employment onany basis prohibitedbyapplicable local,stateorfederallaw.
Iunderstandthatthisapplicationremainscurrentforonly30days.Attheconclusionofthattime,ifIhavenotheardfromtheemployerandstillwishtobeconsideredforemployment,itwill benecessaryfor me toreapply andfill out anewapplication.
IfIamhired,IunderstandthatIamfreetoresign atanytime,with ourwithoutcauseandwithorwithoutpriornotice,exceptasmayberequiredbylaw.Thisapplicationdoesnotconstituteanagreementorcontractforemploymentforanyspecifiedperiodordefiniteduration.Iunderstandthatnosupervisororrepresentativeoftheemployerisauthorizedtomakeanyassurancestothecontraryandthatnoimpliedoralorwrittenagreementscontrarytotheforegoingexpresslanguagearevalidunlesstheyareinwritingandsignedbytheemployer’spresident.
IalsounderstandthatifIamhired,IwillberequiredtoprovideproofofidentityandlegalauthorizationtoworkintheUnitedStatesandthatfederalimmigrationlawsrequiremetocomplete anI-9Form in thisregard.
ThisCompanydoesnottolerateunlawfuldiscriminationinitsemploymentpractices.Noquestiononthisapplicationisusedforthepurposeoflimitingorexcludinganapplicantfromconsiderationforemploymentonthebasisofhisorhersex,race,color,religion,nationalorigin,citizenship,age,disability, or anyother protectedstatusunderapplicablefederal,state,orlocallaw.ThisCompanylikewisedoesnottolerateharassmentbasedonsex,race,color,religion,nationalorigin,citizenship,age,disability,oranyotherprotectedstatus.TheCompanytakesallcomplaintsofharassmentseriouslyand allcomplaintswillbeinvestigatedpromptly andthoroughly.
Iunderstandthatanyinformationprovidedbymethatisfoundtobefalse,incompleteormisrepresentedinanyrespect,willbesufficientcauseto(i)eliminatemefromfurtherconsiderationforemployment,or(ii)mayresultinmyimmediatedischargefromtheemployer’s service, wheneveritis discovered.
DO NOT SIGN UNTILYOU HAVE READ THE ABOVE APPLICANTSTATEMENT.
IcertifythatIhaveread,fullyunderstandandacceptalltermsoftheforegoingApplicantStatement.