Position Applied For: First Name: Middle Initial: Last Name: Address: Telephone Number: Street Address: City: State: Zip Code:

Transcription

1 576 Edgegrove Road Hanover, PA Phone (717) Fax Step One Introduction Position Applied For: First Name: Middle Initial: Last Name: Address: Telephone Number: Street Address: City: State: Zip Code: Have you lived at this address for 3 years or more? Previous Address: Did you live at this previous address for 3 years or more? List any other names under which you were employed or attended school: Step Two More Information About You How did you learn about us? If you are under 18 years of age, can you provide required proof of your eligibility to work? Have you ever filed an application with us before? If Yes, Please give date: Are you currently employed? May we contact your present employer?

2 Are you currently on Lay off status, and subject to recall? Have you ever been convicted of, or pled guilty or no contest to a misdemeanor or felony, such as fraud, embezzlement or misappropriation of funds, or false use of financial instruments, or any other crime involving dishonesty? If Yes, please give date, place charge, and disposition of case. Step Three Limitations/Availability Do you have any limitations regarding the hours that you can work? If Yes, please explain: Do you have reliable transportation? Do you have any friends or relatives currently employed at Conewago? If Yes, Please list names: When will you be available for work? Step Four Certifications Do you have a current: First Aid Certification First Aid Certification: Yes No Expiration Date/Certifying Agency: CPR Certification CPR Certification: Yes No Expiration Date/Certifying Agency: OSHA 10 Hour Construction Safety Training Yes No

3 Step Five Military Service US Military Service Yes No Branch of Service Length of Service Rank/Rate at Time of Discharge Are you a member of the Armed Forces Reserve? Step Six Accommodations and Transportation Are you fully able, with or without assistance to perform the essential functions of the position for which you applied? Describe how you would perform the job with or without reasonable accommodation: Do you have a current Drivers License? State: Number: Class: Expiration Date: List all moving motor violations (other than parking) for the last 3 years:

4 Step Seven Education High School or GED Name of School Address of School Course of Study Years Completed Degree/Diploma College Name of School Address of School Course of Study Years Completed Degree/Diploma Trade School/Other Name of School Address of School Course of Study Years Completed Degree/Diploma Military Name of School Address of School Course of Study Years Completed Degree/Diploma Step Eight Employment Experience

5 Employer #1 Name of Employer Address Telephone Date Started Starting Salary/Wage Starting Position Ending Date Ending Salary/Wage Ending Position Supervisor Name & Title Reason for Leaving Brief Description of Job Duties Employer #2 Name of Employer Address Telephone Date Started Starting Salary/Wage Starting Position Ending Date Ending Salary/Wage Ending Position Supervisor Name & Title Reason for Leaving Brief Description of Job Duties

6 Employer #3 Name of Employer Address Telephone Date Started Starting Salary/Wage Starting Position Ending Date Ending Salary/Wage Ending Position Supervisor Name & Title Reason for Leaving Brief Description of Job Duties List Professional, Civic, or Trade Organization memberships, and any offices held. References (Name/Address/Phone) Step Nine Voluntary Self Identification of Disability Please check one of the boxes below: Yes, I have a disability No, I don t have a disability I don t wish to answer

7 Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Step Ten Appendix B to Part Pre Offer Invitation to Self Identify Veteran Status As a Government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA. I am not a protected Veteran I identify as one or more of the classifications of protected Veterans listed at the link above Step 11 EEO 1 Self Identification Data Record Please check one of the following boxes: Sex Male Female Are you Hispanic or Latino? Yes No What race(s) do you consider yourself to be: White Black/African American Native American/Native Alaskan Asian Native Hawai ian or other Pacific Islander Two or more Races Important Authorization and Understanding Please read this statement, and acknowledge that you have read it. 1. Completeness and accuracy of information. I represent that all of the information now or hereafter given by me in support of my application for employment is true and complete. I understand, that if I am hired, any false or misleading information in support of my application may subject me to discharge at any time during the period of my employment. 2. Authorization for release of information and release from liability. I authorize you to verify any of the information given during the application process with appropriate individuals, companies, institutions, or agencies and I authorize them to release such information as you require, including my prior disciplinary employment record, without any obligation to give me written notice of disclosure. I hereby release you and them from any liability whatsoever as a result of such inquiries and disclosures.

8 A photocopy or other electronic reproduction of this authorization/release is binding, and may be relied upon. 3. Employment at will. I understand that if I am employed, I will be an employee at will. This means that either the employer or the employee may terminate the employment relationship with or without cause at any time. 4. No written, oral, or implied contracts. I understand that any written Company documents, oral statements, or formal or informal policies are not to be construed as granting an express or implied employment contract and that I am not entitled to rely upon any such documents, statements or Company policies as stating employment terms. The employment relationship with the Company may be modified only in writing directed to me by the President of the Company. 5. Benefits may be altered. I understand that the Company at its option may change, delete, suspend, or discontinue any part or parts of its benefit program at any time without prior notice, both while persons are actively employed and while retired or otherwise separated from employment with the Company. 6. I understand that a test for drug and alcohol misuse may be required as part of the interview process, and I hereby authorize the release of test results to the Company. I hereby consent to the performance of such medical examination and testing. I waive all claims arising out of these procedures against the Company and those performing the examination and tests. I understand and consent that as a condition of continued employment, I will submit to drug and alcohol testing in the future. I authorize the release of any such subsequent testing to the Company and waive all claims against it or those performing the examination and tests. I understand that I will be subject to immediate termination for failing to submit to examination or testing. 7. If an employment relationship is established, I agree to wear or use all protective clothing or devices as may be required by the Company and to comply with all safety policies and procedures. I acknowledge that I have read and understand the above statement in its entirety, and have had the opportunity to ask questions regarding any aspect