Basic Information

Position applied for*

Referred source*

Name*

Email*

Cell phone*

Home phone

Current address*

Are you at least 18 years of age?*YesNo

Are you legally eligible to work in the United States?*YesNo

Proof of employment eligibility will be required if hired.

AVAILABILITY

What category would you prefer?Full-timePart-time Temporary

What date can you start?

PROFESSIONAL LICENSES AND CERTIFICATIONS

Do you hold any professional licenses or certifications?* YesNo

Has your license/certification ever been revoked or suspended? YesNo

If yes, state the reason(s), date of revocation or suspension, and date of reinstatement:

REFERENCES

Include only individuals familiar with your work ability. Do not include relatives or names of supervisors listed.

REFERENCE-1

Name*Phone*Year of know/Relationship*Address*

REFERENCE-2

NamePhoneYear of know/RelationshipAddress

REFERENCE-3

NamePhoneYear of know/RelationshipAddress

Education

HIGH SCHOOL

Name

Address

Graduated

COLLEGE

Name

Address

Graduated

Degree Type

OTHER

Name

Address

Graduated

Degree Type

MILITARY

Branch

Date

Rank at discharge

Type of discharge

If other than honorable, explain: Veteran Identification
1 . This employer is a Government contractor subject to the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. § 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications are defined as follows:

A “disabled veteran” is one of the following: a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or a person who was discharged or released from active duty because of a serviceconnected disability.

A “recently separated veteran” means any veteran during the threeyear period beginning on the date of such veteran’s discharge or release from active duty in the U.S. military, ground, naval, or air service.

An “active duty wartime or campaign badge veteran” means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.

An “Armed forces service medal veteran” means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.Protected veterans may have additional rights under USERRA—the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service.

For more information, call the U.S. Department of Labor’s Veterans Employment and Training Service (VETS), tollfree, at 18664USADOL.

2. If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below. 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.

Classification*identify as one or more of the classifications of protected veteran listed aboveI am not a protected veteran

Previous Employment

Your application may not be considered unless every question in this section is answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are critical. ask for a phone book or call information if necessary. for Employers Outside the US., a Current fax number is Mandatory.

MOST RECENT EMPLOYER

Company Name*

Dates*

Supervisor Name

Job Title*

Duties:

Reason for leaving

Address

If yes, may we contact?

Are you currently working for this employer?

Where you subject to FMCSRs** while employed?

Was your job designated as a safety-sensitive function in any DOT-regulated mode to the drug and alcohol testing requirements of 49 CFR Part 40?

**Federal Motor Carrier Safety Regulations apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,0001 or more, (2) is designated or used to transport more than 8 passengers (including driver) , OR (3) any size vehicle used to transport hazardous material in a quantity requiring placarding.

MOST RECENT EMPLOYER - 2

Company Name

Dates

Supervisor Name

Job Title

Duties:

Reason for leaving

Address

If yes, may we contact?

Are you currently working for this employer?

Where you subject to FMCSRs** while employed?

Was your job designated as a safety-sensitive function in any DOT-regulated mode to the drug and alcohol testing requirements of 49 CFR Part 40?

MOST RECENT EMPLOYER - 3

Company Name

Dates

Supervisor Name

Job Title

Duties:

Reason for leaving

Address

If yes, may we contact?

Are you currently working for this employer?

Where you subject to FMCSRs** while employed?

Was your job designated as a safety-sensitive function in any DOT-regulated mode to the drug and alcohol testing requirements of 49 CFR Part 40?

MOST RECENT EMPLOYER - 4

Company Name

Dates

Supervisor Name

Job Title

Duties:

Reason for leaving

Address

If yes, may we contact?

Are you currently working for this employer?

Where you subject to FMCSRs** while employed?

Was your job designated as a safety-sensitive function in any DOT-regulated mode to the drug and alcohol testing requirements of 49 CFR Part 40?

DRIVER'S LICENSE INFORMATION

If the job requires, do you have the appropriate valid driver’s license?

License information

Have you had any moving violations within the last seven years? Please Discribe

Voluntary Self-Identification of Disability

Why do I ask to complete this form?
Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities. To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask of all our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

How do I know if I have a disability?
You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.Disabilities include, but are not limited to: Blindness, Deafness, Cancer, Diabetes, Epilepsy, Autism, Cerebral palsy, HIV/AIDS, Schizophrenia, Muscular dystrophy, Bipolar disorder, Major depression, Multiple sclerosis (MS), Missing limbs or partial missing limbs, Post-traumatic stress disorder (PTSD), Obsessive compulsive disorder, impairments requiring the use of a wheelchair, &/or Intellectual disability (previously called mental retardation)

Please select one of the options below*Yes, I have a disability (or previously had a disability)No, I don't have a disabilityI don't wish to answer

Reasonable Accommodation Notice:
‍Federal law requires employers to provide reasonable accomodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accomodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of federal contractors, visit the U.S. Department of Labor's Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.Form CC-305, OMB Control Number 1250-0005, Expires 01/31/2017

CERTIFICATION AND RELEASE

I understand that this application form is intended for use in evaluating my qualifications for employment and that this application is not an offer of employment. I further understand that if hired, my employment will be considered “at-will” and that my employment may be terminated for any reason, with or without cause or notice, at any time by me or the Company and that this application is not intended to constitute a contract of continued employment.

I certify that the information submitted by me on this application is true and complete. I understand that any false information, misrepresentations or omissions on this application, on other written materials, or provided during any interviews will lead to the rejection of my application or, if I am employed, discipline up to and including termination at the time such false information or omission is discovered.I understand that additional testing of job-related skills and for the presence of drugs may be required prior to employment.

I also understand that after an offer of employment and prior to reporting to work, I may be required to submit to a medical review and depending on Company policy and the needs of the job, I may be required to complete a medical history form and be examined by a medical professional designated by the company. I also understand that i may not be under the influence of drugs or alcohol during employment and that if Company policy so requires, I may be required to submit to drug and/or alcohol testing at an approved testing facility.

I understand that smoking is prohibited in all indoor areas of the Company’s facilities unless designated smoking areas have been established at a particular location in accordance with applicable state and local law.I authorize the Company and/or its agents, including consumer reporting bureaus, to investigate and verify any of the information provided by me.

I authorize my former employers, educational institutions, references and any relevant agencies to provide information to the Company and/or its agents concerning my background and experience. i release the Company and all parties providing information to the Company about my background and experience from any liability whatsoever arising therefrom.

Electronic Signature*

Date*

This application will only be considered for 90 days. If you have not been hired within 90 days of filling out and submitting this application and you wish to be considered for future employment, you must complete a new application.

Self Identification

Completion of this data is completely voluntary; however, we are required to ask if you will volunteer this information. This form will be used for EEO-1 reporting purposes only and will be kept separate from all other personnel records only accessed by Human Resources.

Gender

Race / Ethnicity*Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. White (Not Hispanic or Latino) - A person with origins in any of the original peoples of Europe, the Middle East or North Africa. Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa or other Pacific Islands. Asian (Not 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. American Indian or Alaska Native (Not Hispanic or Latino) - 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 attachmentTwo or More Races (Not Hispanic or Latino) All persons who identify with more than one of the above five races. Prefer not to Answer

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APPLICANT INSTRUCTIONS

Employment Application

Basic Information

AVAILABILITY

PROFESSIONAL LICENSES AND CERTIFICATIONS

REFERENCES

REFERENCE-1

REFERENCE-2

REFERENCE-3

Education

HIGH SCHOOL

COLLEGE

OTHER

MILITARY

Previous Employment

MOST RECENT EMPLOYER

MOST RECENT EMPLOYER - 2

MOST RECENT EMPLOYER - 3

MOST RECENT EMPLOYER - 4

DRIVER'S LICENSE INFORMATION

Voluntary Self-Identification of Disability

CERTIFICATION AND RELEASE

Self Identification