Employment Application

Transcription

1 GENERAL INFORMATION Last Name First Name Middle Initial Street Address & Apt # City State Zip Cell Phone (With area code) Other Phone (With area code) Home Work Have you previously used names other than what is provided above? Are you at least 18 years of age? Yes No Yes No If yes, please specify: Job applied for (Title): How did you learn of this vacancy? Salary Requirements: Are you available to work: Full-time Part-time Days Evenings Weekends A variable schedule Date Available: Have you ever been employed by the? Yes No If yes, please list the job title, department, and dates. Are you now or have you ever been a volunteer for the Nebraska Humane Society? Yes No If yes, please list the job title, department, and dates. Are you eligible for employment in the United States? Yes (Proof of eligibility will be required upon employment.) No Have you ever been convicted of a felony or misdemeanor other than a minor traffic offense? Yes If yes, please explain. No A record of conviction will not necessarily bar you from employment. EDUCATION High School Name City State Diploma/Equivalent? Yes No College and/or Technical School Name Other Training or Degrees School Name City State Degree? Yes No Major If degree not earned, years completed: City State Degree? Yes No Major If degree not earned, years completed: PROFESSIONAL LICENSES (If hired, you will be required to provide proof of licensure.) Title No. State Expiration Date Title No. State Expiration Date Page 1 of 6

2 EMPLOYMENT HISTORY: (List employment for last 10 years beginning with current/last employer. You may include U.S. military service. ) 1st. EMPLOYER NAME Address City State Zip Code Telephone No Your Title Department ( ) Beginning Date Ending Date Final Salary Supervisor's Name & Title Summary of duties: Reason for leaving: May we contact your employer? Yes No 2nd. EMPLOYER NAME Address City State Zip Code Telephone No Your Title Department ( ) Beginning Date Ending Date Final Salary Supervisor's Name & Title Summary of duties: Reason for leaving: May we contact your employer? Yes No 3rd. EMPLOYER NAME Address City State Zip Code Telephone No Your Title Department ( ) Beginning Date Ending Date Final Salary Supervisor's Name & Title Summary of duties: Reason for leaving: May we contact your employer? Yes No If you need more space, please attach a separate sheet of paper indicating the above information for each additional job. Have you ever been discharged or asked to resign from a job? Yes No If yes, explain. SKILLS List software in which you are proficient: Second Languages, Including Sign Language. Language(s) Are you bilingual? Yes No Fluency: Spoken: Excellent Good Fair Poor Written: Excellent Good Fair Poor Please list any other skills relevant to the job for which you are applying: Page 2 of 6

3 DRIVING INFORMATION (Please complete if you are applying for a job that requires driving NHS vehicles.) Driver s License Number: Issuing State: Expiration Date: Has your driver's license ever been suspended or revoked? Yes No If yes, please explain: Have you ever had any chargeable accidents or moving violations in the past 7 years? Yes No If yes, please explain: Is your knowledge of our city streets good? Yes No REFERENCES (Please list 3 business references other than those listed in the employment section.) Reference 1 Reference 2 Reference 3 Name Occupation Company Address Telephone Years Known Professional relationship to applicant. I hereby certify that the facts set forth in this employment application are true and complete to the best of my knowledge. I understand that misrepresentation or omission of facts, regardless of date of discovery, may result in termination or the withdrawal of an offer of employment. I further understand that any employment offered is for an indefinite duration, unless otherwise specified in writing, and is at-will, which means that either I or the may terminate my employment at any time with or without notice or with or without cause. I understand that neither the policies, rules, regulations of employment, application for employment, nor anything said during the interview process shall be deemed to constitute an offer of or the terms of any implied employment contract. I authorize investigation and verification of all statements contained in this application for employment. I further authorize the Nebraska Humane Society to contact and/or interview any additional individuals, institutions and employers the becomes aware of during its investigation. Signature of Applicant: Date: Thank you for your interest in employment with the. In order to have your application processed, you must thoroughly answer all questions on the application form. Applications filled out incompletely will not be considered. While we encourage you to attach a resume, please note that a resume will not substitute for completing any portion of this application. The use of this form does not necessarily indicate that positions are open nor does it constitute an offer of employment or a contract of employment. The is an Equal Opportunity Employer and we consider applicants for all p ositions without regard to race, color, religion, sex, sexual orientation, gender identity, age, national origin, disabled or veteran status, or other legally protected status. Page 3 of 6

4 Applicant Consent to Drug Test/Back Screen and Release To the Applicant: As part of its program to provide a safe and healthy work environment, the Nebraska Humane Society may ask you to take a drug test for a position for which you have received a conditional offer of employment. If the test is confirmed as positive, the results will be considered in any employment decision and will result in the withdrawal of a conditional offer of employment. Refusal to submit to testing will also result in the withdrawal of a conditional offer of employment. In addition to a drug test, some positions require a post offer, pre-employment back screen or physical examination. If the back screen or physical examination results show that an applicant is unable to perform the essential functions of the position, with or without a reasonable accommodation, the applicant may be denied employment. Refusal to consent to a drug test or back screen/physical examination may result in denial of employment. Consent and Release I,, have read the foregoing statement and understand that the employment screening process may include a urine or other test which may detect the presence of illegal narcotics, including marijuana and other drugs, as well as signs of abuse of legal drugs. I also understand that the employment screening process may include a back screen or physical examination for some positions. I hereby consent and agree to undergo such test(s)/examinations as requested by the Nebraska Humane Society. I also consent to the release and disclosure of the results of the test(s)/examinations to the. I hereby release and discharge the and any of its designated medical personnel, agents, or authorized testing laboratories or clinics from any claim or liability arising out of or related to any such test(s)/examinations or the results of such tests or examinations that I have been asked to undergo by the, including, without limitation, the testing procedures, the analysis or the disclosure of its results. I further consent, if hired, that my employment is subject to the s policies and rules, as amended from time to time. I understand that, if hired, my employment with the will be at-will, which means that either I or the Nebraska Humane Society may terminate my employment at any time with or without notice or with or without cause. Printed Name Signature Date Page 4 of 6

5 DISCLOSURE REGARDING PROCUREMENT OF CONSUMER REPORTS Important: Please read carefully. DISCLOSURE The, or a third-party consumer reporting agency acting on its behalf, may obtain or procure a consumer report in connection with your application for and/or continued employment with the. A consumer report may include information concerning your background including, but not limited to: information about your personal character, previous employment, general reputation, personal characteristics, educational background, qualifications, financial and credit history, driving record, and/or criminal history. These reports may include experience information along with reasons for termination of past employment. Further, information from various Federal, State, local and other agencies which contain your past activities may be requested. A consumer report may be obtained at any time during the application process or during your employment, if any, with the Nebraska Humane Society. The will provide you with written notice before any adverse employment action is taken based in whole or in part on information contained in a consumer report, including a copy of the consumer report; the name, address and telephone number of the reporting agency; and a summary of your rights under the Fair Credit Reporting Act. The may provide the results of any consumer report to any contractor for whom you are assigned to perform work on behalf of the Nebraska Humane Society. If you wish the to consider you for employment or continued employment, please sign the attached authorization, which authorizes the Nebraska Humane Society to obtain this consumer report. Page 5 of 6

6 AUTHORIZATION TO PROCURE CONSUMER REPORTS I hereby authorize the, or a third-party consumer reporting agency acting on its behalf to obtain or procure a consumer report in connection with my application for and/or continued employment with the. I understand that such consumer report may include information concerning my background including, but not limited to: information about my personal character, previous employment, general reputation, personal characteristics, educational background, qualifications, financial and credit history, driving record, and/or criminal history. I hereby authorize and request, without any reservation, any and all present or former employers; schools; police departments; financial institutions; divisions of motor vehicles; consumer reporting agencies; persons,; corporations; credit agencies; education institution; law enforcement agencies; city, state, county, or federal courts; military services; or other persons or agencies having knowledge about me to furnish the, or any third party acting on the 's behalf, with any and all background information in their possession regarding me, in order that my employment qualifications may be evaluated. Moreover, I further authorize the ongoing procurement of the above-mentioned consumer reports at any time during my employment, if any, with the. I also agree that a fax or photocopy of this authorization with my signature be accepted with the same authority as the original. I understand that the and its agents are not responsible for the accuracy or completeness of the information contained in any background consumer report. I understand that the obtains consumer reports from a company called Protec. I understand that pursuant to the Fair Credit Reporting Act, if requested within 60 days, I will be given full disclosure as to the nature and substance of all information provided to the Nebraska Humane Society. I further understand that the company will provide me with written notice if any adverse employment action is to be taken based in whole or in part on information contained in a consumer report within the meaning of the FCRA. I understand that this authorization is not an offer for employment by the Nebraska Humane Society, and that any false or misleading information I have provided to the Nebraska Humane Society may result in a refusal to hire, promote, reassign or continue employment. I understand and agree that the may provide the results of my background investigation report to any contractor for whom I may be assigned to perform work on behalf of the. I have received and read the attached disclosure regarding the s right to obtain a background consumer report for employment purposes, and I authorize the Nebraska Humane Society to obtain such a report. Applicant s Signature Applicant s Printed Name Date Social Security Number Page 6 of 6