Employment Application

Date of Application:

LGB is an Affirmative Action/Equal Opportunity Employer and does not discriminate on the basis of race, color, religion, age, sex, marital status, national origin, disability, veteran status or any other protected class.

Name: Social Security Number:

LastFirstMiddle

Address:

Number/StreetCityStateZip

Phone Numbers: ______

Residence BusinessCellE-mail Address

Position for which you are applying:

Salary Requirements: ______ Annual rate Hourly rate

Are you 18 years of age or older? Yes NoIf not, list date of birth

Are you legally permitted to work in the U.S? Yes No

Have you ever been convicted of a felony? Yes No

The fact that you have a record of conviction will not necessarily bar you from employment.If “Yes,” explain fully (including Location and Date) on separate page.

Have you previously been employed by LGB & Associates, Inc.? Yes No

If yes, complete the following:

Last Location/Project:Last Supervisor:

Last position held:Separation Date:

Under what name you worked:

Education(include all periods of schooling beginning with high school.)
Name and address of High School / Graduated / GED
 Yes
 No /  Yes
 No
Name and Address of College(s) or other School(s) /
Major Field
/ Degree Received or Expected Degree(If applicable)

WORK HISTORY FOR LAST 15 YEARS IF APPLICABLE

Indicate all regular, cooperative, summer and voluntary work. List most recent first and continue on separate sheet if necessary.

Name and
Address of Employer / Dates
Employed / Title / Name and Phone No. of Supervisor / Salary
From:
To: / Start: $
Finish: $
Description of general duties:
Reason for leaving:
Name and
Address of Employer / Dates
Employed / Title / Name and Phone No. of Supervisor / Salary
From:
To: / Start: $
Finish: $
Description of general duties:
Reason for leaving:
Name and
Address of Employer / Dates
Employed / Title / Name and Phone No. of Supervisor / Salary
From:
To: / Start: $
Finish: $
Description of general duties:
Reason for leaving:
Name and
Address of Employer / Dates
Employed / Title / Name and Phone No. of Supervisor / Salary
From:
To: / Start: $
Finish: $
Description of general duties:
Reason for leaving:

I give permission for LGB to contact my current/most recent employer.  Yes No

Please provide 3 professional references.

Name, E-mail and Phone / Title / Relationship to Applicant
1.
2.
3.

I give permission for LGB to contact my references. Yes No

U.S. Military Service

Branch: Highest Rank Achieved:

Dates of Service:

Duties:

Security Clearance

Have you ever held a SecurityClearance?  Yes  No If Yes, what level? ______Dates: ______

Do you currently have a SecurityClearance?  Yes  No If Yes, what level? ______Dates: ______

Comments:

Professional Registration or Licenses/Other Activities/Other Skills

Professional, School, Campus, Community, or Leisure Activities

Note Special Licenses or Certifications with numbersActive: Yes/No

Additional Information

What prompted your application?

Walk-in Recruited Internet Agency Referral Career Fair Open House

Newspaper Employee Referral (Name)

Other

Have you signed a non-compete agreement or other similar contract that may restrict your ability to work for a former employer’s competitors or clients?  Yes  No

If yes, you will be required to provide a copy with this application.

AS AN APPLICANT YOU AGREE TO AND UNDERSTAND THE FOLLOWING:

I hereby authorize LGB & Associates, Inc. to thoroughly investigate my background, references, employment record and other matters related to my suitability for employment. I authorize persons, schools, my current employer (if applicable), and previous employers and organizations contacted by LGB & Associates, Inc. to provide any relevant information regarding my current and/or previous employment and I release all persons, schools and employers of any and all claims for providing such information. I understand that misrepresentation or omission of facts may result in rejection of this application, or if hired, discipline up to and including dismissal. I understand that I may be required to sign a confidentiality and/or non-compete agreement, could I become an employee of LGB & Associates, Inc. I understand that nothing contained in this application, or conveyed during any interview that may be granted is intended to create an employment contract.

I understand that acceptance of an offer of employment does not create a contractual obligation upon the employer to continue to employ me in the future and acknowledge that any employment relationship with LGB & Associates, Inc. is of an “at will” nature in which either party is free to terminate for any reasons. It is further understood that this “at will” employment relationship may not be changed by a written document or by conduct unless such a change is specifically acknowledged in writing by an authorized officer of LGB & Associates, Inc.

I have read and understand the above Agreement. This application is complete and accurate to the best of my knowledge.

Signature of ApplicantDate

Affirmative Action Program Applicant Information Form

LGB is an Equal Opportunity Employer. As required by law, we must record certain information to be made a part of our Affirmative Action Program.

Applicants for employment are also invited to participate in the Affirmative Action Program by reporting their status. In extending this invitation you are also advised that: (a) workers (applicants) are under no obligation to respond, but may do so in the future if they choose; (b) responses will remain confidential within the Human Resources Department; and (c) responses will be used only for the necessary information to include in our Affirmative Action Program. We are a company that values diversity. We actively encourage women and minorities to apply. Refusal to provide this information will have no bearing on your application and will not subject you to any adverse treatment.

Please complete the information requested below. Thank you for your cooperation.

Section 1: General Applicant Information

Name / Date
_____/_____/_____
Position applied for

Section 2: Please check as applicable (See reverse for definitions)

Race or Ethnic Identity / Gender
Hispanic or Latino
White
Black or African American
Native Hawaiian or Pacific Islander
Asian
American Indian or Alaskan Native
Two or More Races / Male
Female
I do not wish to Self-IdentifySignature ______
How did you hear of our opening?
Current Employee Newspaper Ad Recruiter Other - Explain Below:
For Human Resources Use Only: / Requisition # / Job Group

EEOC RACE/ETHNIC IDENTIFICATION CATEGORIES

Hispanic or Latino

A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.

White

A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Black or African American

A person having origins in any of the black racial groups of Africa.

Native Hawaiian or Other Pacific Islander

A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other PacificIslands.

Asian

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.

American Indian or Alaska Native

A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.

Two or More Races

All persons who identify with more than one of the above five races.

DCS No. 118 Effective Date

Revision 4.0 02/01/07 Page 1 of 7