VOLUNTARY AFFIRMATIVE ACTION QUESTIONNAIRE

Transcription

1 VOLUNTARY AFFIRMATIVE ACTION QUESTIONNAIRE This form is required by the U.S. Department of Labor to assist in monitoring Affirmative Action Programs and to aid the company in complying with any required governmental record keeping or periodic reporting. If you choose to provide the information, please complete the following information, print so we can read what you wrote, place the form in the attached envelope, seal the envelope and turn it in with your application. If you prefer not to complete the form, the items in red or marked with an * must be completed anyway. This information is not part of your employment application, and won t be considered in the employment/selection process. Name of company you are applying to*: Title of job applied for*: State where application will be turned in*: Your name*: Your address*: Street & Number City State Zip Your phone number*: _( ) Today s date*: Your date of birth: Gender: Male Female RACE (check one) White - origins in Europe, North Africa, or Middle East. Black - origins in any of the Black African racial groups not of Hispanic origin Hispanic - Mexican, Puerto Rican, Cuban, Central or S. American or other Spanish Culture or origin, regardless of race Asian and Pacific Islander - origins in Far East, S.E. Asia, the Indian Subcontinent, or the Pacific Islands American Indian or Alaskan native - origins in North America, to include Alaska, and maintaining identifiable tribal affiliations through membership and participation or community identification Two or more races VETERAN/U.S. MILITARY STATUS (check one) Non-Veteran Pre-Vietnam Veteran Pre-Vietnam Veteran with service incurred disability Vietnam Era Veteran (8/5/64-5/7/75) Vietnam Era Veteran with service incurred disability Post Vietnam Era Veteran Post Vietnam Era Veteran with service incurred disability REFERRAL SOURCE. HOW DID YOU LEARN ABOUT A JOB HERE? (check one) Workforce Development Friend Relative Current Employee Employment agency Walk-in Other Union (Which union?) Advertisement (Which newspaper?) In the event you are hired, information on this form will not be kept in your personnel file. In compliance with all Federal and State equal employment laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, or non-job related disability. REVISED 5/11

2 McCarthy-Bush Family of Companies General Application for Employment Date Received by Company / / We are an Equal Employment Opportunity Employer. In compliance with all Federal and State equal opportunity employment laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, sexual orientation, disability, or any other class protected by law. If mailing, return to: McCarthy-Bush Corp., ATTN: Human Resources, 5401 Victoria Ave., Davenport, IA To be considered for employment you must truthfully complete every section, answer every question, or write NO, NONE or N/A. Even if you attach a resume, answer the question. See Resume is not acceptable. PLEASE PRINT CLEARLY Name First Middle Last Current Address Social Security # - - Are you 18 years of age or older? Yes No Home phone ( ) Cell phone ( ) Address List any additional address information for the last 7 years: Are you legally authorized to work in the United States? Yes No Have you ever worked for McCarthy-Bush Corp. or any related company before? No Yes If so, when and what position? Did anyone refer you to us? No Yes If so, who? (Please include Union referral information): McCarthy-Bush Corp. and its affiliates are drug and alcohol-free workplace employers. Unless an applicable collective bargaining agreement provides otherwise, applicants are required to submit to a post-offer, pre-employment drug test. General Application, January 2014, Page 1 of 5

3 Employment History You will not be considered for employment if you do not follow these instructions. You must: 1) List all employers for the last 10 years in order, starting with your most recent or present job; and 2) Answer all questions for each employer or explain why you are not answering. MOST RECENT EMPLOYER: Employer address: _ Contact person: Reason for leaving: If still employed with this Employer, may we contact? YES NO Employer address: _ Contact person: Reason for leaving: Employer address: _ Contact person: Reason for leaving: General Application, January 2014, Page 2 of 5

4 Employer address: _ Contact person: Reason for leaving: Employer address: _ Contact person: Reason for leaving: Education Circle the highest grade completed: High School: GED College Please list all College, Trade or Vocational Schools: School Address Years Attended Degree/Certificate School Address Years Attended Degree/Certificate School Address Years Attended Degree/Certificate Experience Please List all types of motor vehicle and/or equipment experience Type of Vehicle/Special Equipment How Much Experience Dates of Experience General Application, January 2014, Page 3 of 5

5 Criminal Convictions You must list all misdemeanor and felony convictions, including pleas of guilty. If no convictions, check the box. You are not required to list arrests that did not result in conviction or any convictions expunged by court order. I have had NO criminal convictions. Location of Conviction (County & State) Conviction Offense Year (If you have more convictions not listed, check this box Driver s License Information and attach and additional sheet.) My driver s license is: Valid Revoked Suspended Expired I do NOT have a license Driver s License Number Issuing State Expiration Has your license ever been suspended or revoked or your driving privileges denied? No Yes If you answered Yes, please explain when and why: Certification and Acknowledgement PLEASE READ AND SIGN BELOW I agree that I have read and understood this application and that this does not create, and is not intended to create, a contract for or a guarantee of employment. I understand that if I am employed, and unless I am covered by a collective bargaining agreement that provides differently, my employment is for no definite period of time and may be terminated at any time, with or without prior notice, at the option of either myself or the company, and that no promises or representations are binding on the company unless made in writing and signed by an authorized representative of the company. I understand that McCarthy-Bush Corporate and its affiliates maintain alcohol and drug-free workplaces. In the event I am offered employment, I understand that I will be required to submit to a pre-employment drug test and must test negative before beginning employment unless I am covered by a collective bargaining agreement that provides differently. A positive pre-employment drug test result will result in the offer of employment being withdrawn and ineligibility for employment with McCarthy-Bush Corporate and its affiliates for a period of 2 years. In the event of employment with McCarthy-Bush Corp. or its affiliate, I understand that any false, inaccurate or misleading information provided on this application or in any communications during evaluation of my qualifications for employment will be grounds for immediate termination from employment. Applicant Signature Date Print Name General Application, January 2014, Page 4 of 5

6 NOTICE AND AUTHORIZATION FOR AN INVESTIGATIVE REPORT READ, COMPLETE AND SIGN AT THE BOTTOM The federal Fair Credit Reporting Act (FCRA) is designed to promote accuracy, fairness, and privacy of information investigated and provided by "consumer reporting agencies" (CRA). CRAs include third-party person s or businesses that, for monetary fees, regularly investigate, provide or evaluate information on consumers for the purpose of furnishing consumer reports to potential employers, including credit reports, motor vehicle reports (MVR), criminal records, civil lawsuits and reference checks. You may have additional rights under state law. You may contact a state or local consumer protection agency or a state attorney general to learn those rights. In connection with my application, I understand that an investigative consumer report may be requested and may include information related to my character, work habits, credit, academic-credentials verification, job performance, experience and reasons of termination. I understand that McCarthy-Bush Corp. or its affiliate may request information concerning my driving record, criminal background and/or results from my participation in any employment related drug or alcohol testing program, from various sources. I also understand that if I am covered by a collective bargaining agreement that would prohibit such requests for information, no such information requests will be made. I understand that in order to obtain an investigative consumer report, it may be necessary that my name, address, date of birth and social security number be provided to positively identify me. I authorize the use, and disclosure, of this information and any other information provided by me in this application for employment by any McCarthy-Bush Family of Companies affiliate and their authorized representatives. I acknowledge the following rights: If any information from the CRA is taken against me, such as denying employment, I must be provided with the name, address, and phone number of the CRA that provided the consumer report. I can request a copy of the information to be provided at no charge within 60 days of the action taken against me. I can dispute the accuracy of the information and the CRA must conduct an investigation within 30 days (unless a frivolous dispute). The result of the investigation must be provided to me in writing. Any information found to be inaccurate or incomplete must be removed or corrected within 30 days. I can dispute the accuracy of the information directly with the source that provided it to the CRA. If a CRA or the employer violates the FCRA, I may sue them in state or federal court. I agree that my current and any prospective employer may release qualitative information related to my employment, including but not limited to my quality of work, productivity, attendance, reliability and working relationships, and waive written notice regarding the release of such information. I further agree to hold any current or former employer harmless from liability for statements made to McCarthy-Bush Corp., any affiliate or their authorized representatives about my previous employment. Applicant Signature Date Print Name Social Security Number Birth Date Please list any alias or maiden name(s): Driver s License Number Issuing State Expiration Your application is COMPLETE. Thank you for choosing McCarthy-Bush Family of Companies! General Application, January 2014, Page 5 of 5