Equal Employment Opportunity (EEO) Self-Identification Form (completion of this form is voluntary)

Transcription

1 Equal Employment Opportunity (EEO) Self-Identification Form (completion of this form is voluntary) Hoffman & Hoffman, Inc. ( Company ) is an equal employment opportunity/affirmative action employer. It does not discriminate on the basis of race, color, national origin, sex, religion, ancestry, age, sexual orientation, marital status, disability, veteran status, citizenship status, or any other protected characteristic. Certain laws and regulations regarding equal employment opportunity, and/or affirmative action direct us to compile, maintain, and report certain information on employees. In order to comply with these laws and regulations, we are requesting your cooperation in completing this voluntary EEO Self-Identification Form. The information on this EEO Self-Identification Form is being requested and will be used solely for record keeping and reporting purposes. Submission of this form by you is voluntary. Please be assured that you will not be subjected to any adverse treatment if you do not provide the information requested. In the event that you do provide the information requested, the information and this form will be processed and maintained separately from your employment application forms. For the purpose of this form, please indicate the group in which you appear to belong, identify with, or are regarded in the community as belonging. However, only count yourself in one ethnic/minority group. Race and Ethnic Identification Hispanic or Latino A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. White (t Hispanic or Latino) A person having origins in any of the original peoples of Europe, the Middle East, or rth Africa. Black or African American (t Hispanic or Latino) A person having origins in any of the Black racial groups of Africa. Native Hawaiian or Other Pacific Islander (t Hispanic or Latino) A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. Asian (t 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 (t Hispanic or Latino) A person having origins in any of the original peoples of rth or South America (including Central America), and who maintains tribal affiliation or community attachment. Two or More Races (t Hispanic or Latino) All persons who identify with more than one of the above races/ethnicities. Gender Female Male Veteran Status (check all that apply) t Applicable Vietnam Era Veteran Armed Forces Service Medal Veteran Recently Separated Veteran Other Protected Veteran Please enter the position for which you applied: Please enter the branch location for which you applied: Name: E-Signature: Date:

2 APPLICATION FOR EMPLOYMENT Hoffman & Hoffman, Inc. is an equal opportunity employer, dedicated to a policy of nondiscrimination in employment on any basis including age, sex, color, race, creed, national origin, religion, marital status, sexual orientation, veteran status, political belief, or disability. Federal law prohibits the employment of unauthorized aliens. All persons hired must submit satisfactory proof of employment authorization and identity within three (3) days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment. Hoffman & Hoffman, Inc. prohibits the use, sale, offer for sale, distribution, possession, or manufacture of illicit drugs or nonmedically prescribed controlled substances on its premises and will not knowingly hire or retain as employees persons who engage in such activities, whether on or off Company property. Employees who work off Company premises at jobsites or other client facilities will be subject to the drug testing policies in effect at those locations. PERSONAL INFORMATION Date Phone Number Address Last Name First Middle Street Address City State Zip Do you currently, or have you in the past, had any type of association with any of the Company s competitors and/or customers? Yes Are you 18 years or older? Yes Are you prevented from lawfully becoming employed in this country because of visa or immigration status? Yes Have you ever been convicted of a felony? Yes Have you been convicted of a misdemeanor within the last five (5) years? Yes EMPLOYMENT DESIRED Position Desired Available Start Date Salary Desired Are you currently employed? Yes May we inquire of your present employer? Yes Do you have a n-compete or n-solicitation Agreement with your current or previous employers? Yes EDUCATION Level Name and Location of School. Years Attended High School Did You Graduate? Main Course Of Study College College Trade Or Business School List any certificate earned and/or any additional training programs not included in your formal education:

3 GENERAL Special Skills: List any professional affiliations to which you belong (please do not list activities which would indicate age, sex, color, race, creed, national origin, religion, marital status, sexual orientation, political belief, or disability): U.S. Military or Present membership in Naval Service: Rank National Guard or Reserves PREVIOUS EMPLOYMENT List below your last THREE employers, starting with the last one first. DATE, MONTH, AND YEAR NAME AND ADDRESS OF EMPLOYER SALARY POSITION AND SUPERVISOR S NAME REASON FOR LEAVING REFERENCES List below the names of three persons, preferably professional associates, who you have known for at least one year. NAME COMPANY ADDRESS AND PHONE NUMBER PROFESSIONAL RELATIONSHP APPLICANT CERTIFICATION AND RELEASE All hiring and employment at Hoffman & Hoffman, Inc. is at will. I understand this application is not an employment contract, nor can it be used to create one. Employment by Hoffman & Hoffman, Inc. has no specific term and may be terminated by the employee or Hoffman & Hoffman, Inc. at any time with or without notice. I acknowledge that Hoffman & Hoffman, Inc. has not made any promises or representations that differ from those contained in this paragraph. I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. In connection with my application for employment and as a condition of continuing employment, I understand that investigative background inquiries may be made on me including previous employers, schools, criminal convictions, motor vehicle, and other reports. These reports may include information as to my character, work habits, performance, education, compensation, and experience along with reasons for termination of employment from previous employers. Furthermore, I understand that the company may be requesting information from various federal, state, and other agencies which maintain records concerning my past activities relating to my driving, credit, criminal, civil, and other experiences. I authorize without reservation, any party or agency contacted to furnish the above mentioned information and release all parties involved from liability in connection with any reporting. I hereby consent to Hoffman & Hoffman, Inc. and/or any of their agents obtaining the above information. This authorization and consent shall be valid in original, fax, or copy form. Date Signature

4 DO NOT WRITE BELOW THIS LINE Interviewed By: Date: Hired: Yes Position: Start Date: Salary: Dept. Manager Approval:

5 Hoffman & Hoffman, Inc. (the Company ) PRE-EMPLOYMENT DRUG TESTING POLICY All job applicants at this Company will undergo screening for the presence of illegal drugs as a condition of employment. Applicants will be required to voluntarily submit to a urine, hair, or oral test(s) at the Company s sole discretion, and release the Company from any liability associated with such testing and its analysis. Any applicant with a positive test result, or who adulterates or substitutes a test sample or who attempts to do so, will be denied employment. Any applicant who refuses to be tested or to provide a sample to be tested will be denied employment. PRE-EMPLOYMENT AGREEMENT PLEASE READ CAREFULLY I freely and voluntarily agree to submit to a drug test as part of my application for employment. I understand that either refusal to submit to a drug test or failure to pass minimum standards established by the Company for this drug test will disqualify me from further consideration for employment. I further understand that if I am hired for employment with the Company, I may be required to submit to a test of my urine, hair, oral fluid, or other testing during employment. I understand that refusal to take a requested substance abuse test or failure to meet the minimum standards set for such testing may result in immediate suspension or termination. In the event that employment commences prior to the Company receiving the drug test results, I understand that I may be immediately terminated if the results come back positive, or reflect an adulterated or substituted specimen. I have read in full and understand the above statements and conditions of employment. Applicant s Signature Date Applicant s Printed Name