Employment Application

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Name *

First

Middle

Last

Telephone # *

Cellular/Other Phone # *

Email Address *

Positions(s) applied for *

Enter the name of the position for which you are applying (ex. Teller - Part Time )

Date of application *

Referral Source (please check the appropriate category and list the source) *

If necessary, best time to call you is

Best contact by *

Home
Cellular/Other

May we contact you at work? *

If yes, work number and best time to call *

If you are under 18 and it is required, can you furnish a work permit? *

If no, please explain

Have you submitted an application here before? *

If yes, give date(s) (mm/dd/yyy) and position(s) *

Have you ever been employed here before? *

If yes, give dates (dd/mm/yyyy) *

Is this application a request for reemployment following an extended military leave of absence from the company? *

If yes, additional information may be requested.

Are you legally eligible for employment in this country? *

Date available for work *

What is your desired salary range or hourly rate of pay? *

Will you relocate if job requires it? *

Will you travel if job requires it? *

If they have been explained to you, are you able to meet the attendance requirements of the position? *

Will you work overtime if required? *

If no, please explain *

Are you able to perform the "essential functions" of the job for which you are applying (with or without reasonable accommodation)? *

This question is not designed to elicit information about an applicant's disability. Please do not provide information about the existence of a disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stage to the extent permitted by law.

Have you ever been bonded? *

Have you entered to an agreement with any former employer or other party (such as a non competition agreement) that might, in any way, restrict your ability to work for our company? *

If yes, please explain *

NOTE TO RHODE ISLAND APPLICANTS: This company is subject to the state's workers' compensation laws (Chapter 29-38) unless otherwise noted below: (list applicable exemptions)

Employment History

Starting with your most recent employer, provide the following information. You may include an verified work performed on a volunteer basis.

Employer Information #1

Employer *

Employer Telephone # *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Starting job title / Final job title *

Immediate supervisor and title (for most recent position held) *

May we contact for reference? *

Yes
No
Later

Employer Email *

Why did you leave? *

Summarize the type of work performed and job responsibilities *

What did you like most about your position? *

What were the things you liked least about your position? *

Dates Employed *

Start Date (mm/yyyy) - End Date (mm/yyyy)

Compensation (Starting) *

Hourly
Salary

Starting Compensation Amount *

Commission/Bonus/Other Compensation *

Compensation (Final) *

Hourly
Salary

Final Compensation Amount *

Commission/Bonus/Other Compensation *

Employer Information #2

Employer

Employer Telephone # *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Starting job title / Final job title *

Immediate supervisor and title (for most recent position held) *

May we contact for reference? *

Yes
No
Later

Employer Email *

Why did you leave? *

Summarize the type of work performed and job responsibilities *

What did you like most about your position? *

What were the things you liked least about your position? *

Dates Employed *

Start Date (mm/yyyy) - End Date (mm/yyyy)

Compensation (Starting) *

Hourly
Salary

Starting Compensation Amount *

Commission/Bonus/Other Compensation *

Compensation (Final) *

Hourly
Salary

Final Compensation Amount *

Commission/Bonus/Other Compensation *

Employer Information #3

Employer

Employer Telephone # *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Starting job title / Final job title *

Immediate supervisor and title (for most recent position held) *

May we contact for reference? *

Yes
No
Later

Employer Email *

Why did you leave? *

Summarize the type of work performed and job responsibilities *

What did you like most about your position? *

What were the things you liked least about your position? *

Dates Employed *

Start Date (mm/yyyy) - End Date (mm/yyyy)

Compensation (Starting) *

Hourly
Salary

Starting Compensation Amount *

Commission/Bonus/Other Compensation *

Compensation (Final) *

Hourly
Salary

Final Compensation Amount *

Commission/Bonus/Other Compensation *

Employer Information #4

Employer

Employer Telephone # *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Starting job title / Final job title *

Immediate supervisor and title (for most recent position held) *

May we contact for reference? *

Yes
No
Later

Employer Email *

Why did you leave? *

Summarize the type of work performed and job responsibilities *

What did you like most about your position? *

What were the things you liked least about your position? *

Dates Employed

Start Date (mm/yyyy) - End Date (mm/yyyy)

Compensation (Starting) *

Hourly
Salary

Starting Compensation Amount *

Commission/Bonus/Other Compensation *

Compensation (Final) *

Hourly
Salary

Final Compensation Amount *

Commission/Bonus/Other Compensation *

Extra

Explain any gaps in your employment, other than due to personal illness, injury or disability

If not addressed on previous page, have you ever been fired or asked to resign from a job? If not addressed on previous page, have you ever been fired or asked to resign from a job?

If yes explain

Skills and Qualifications

Summarize any special training, skills, licenses and/or certificates that may assist you in performing the position for which you are applying *

Computer Skills *

Word Processing
Spreadsheet
Presentation
Email
Internet
Other

Check appropriate boxes.

Software title(s) and years of experience (if applicable).

Educational Background

Starting with your most recent school attended, provide the information requested below.

School #1

School (include City and State) *

Years Completed *

Completed *

GED
Diploma
Degree
Certification
Other

Degree *

Certification *

Other

GPA Class Rank

Major/Minor

School #2

School (include City and State)

Years Completed *

Completed *

GED
Diploma
Degree
Certification
Other

Degree *

Certification *

Other

GPA Class Rank

Major/Minor

School #3

School (include City and State)

Years Completed *

Completed *

GED
Diploma
Degree
Certification
Other

Degree *

Certification *

Other

GPA Class Rank

Major/Minor

School #4

School (include City and State)

Years Completed *

Completed *

GED
Diploma
Degree
Certification
Other

Degree *

Certification *

Other

GPA Class Rank

Major/Minor

References

List names and telephone numbers of three business/work references who are not related to you List names and telephone numbers of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you.

List #1

Name

First

Last

Title

Relationship to You

Telephone

# of Years Known

List #2

Name

First

Last

Title

Relationship to You

Telephone

# of Years Known

List #3

Name

First

Last

Title

Relationship to You

Telephone

# of Years Known

Related Information

To what job-related organization (professional, trade, ect.) do you belong? Exclude memberships that would reveal race, color, sex, national origin, genetic information, citizenship, age, mental or physical disabilities, veteran/reserve, National Guard or any other similarly protected status.

Organization

Offices Held

Organization

Offices Held

Organization

Offices Held

Organization

Offices Held

List special accomplishments, publications, awards, etc.

Exclude information that would reveal race, color, religion, sex, national origin, genetic information, citizenship, age, mental or physical disabilities, veteran/reserve, National Guard or any other similarly protected status.

In your current or previous job, have you ever written instructions or directions to be followed by employees or customers?

Yes
No
Not Applicable

If yes, please explain

Is there any other job-related information you want us to know about?

Voluntary Self-Identification of Race/Ethnicity

Are you Hispanic or Latino? *

A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.

If you answered 'no', please select one of the following categories that best describes your race *

White (Not Hispanic or Latino. A person having 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).
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).
Pacific Islander (Not Hispanic or Latino. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands).
Native American (Not Hispanic or Latino. A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment).
Two or More Races (Not Hispanic or Latino. A person who identifies with more than one of the above races).
Decline to identify

Voluntary Self-Identification of Gender

Gender *

Male
Female
Decline to identify

Voluntary Self-Identify As A Protected Veteran

We are a federal 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 contractors to take affirmative action to employ and advance in employment disabled veterans, recently separated veterans, active duty wartime or campaign badge veterans, and Armed Forces service medal veterans. As a federal contractor, we are required to submit a report to the U.S. Department of Labor each year identifying the number of our employees belonging to each "protected veteran" category. This information is being requested on a voluntary basis and will be kept confidential as required by law. Refusal to provide the requested information will not subject you to adverse treatment. If provided, this information will not be used in a manner inconsistent with VEVRAA. Name: Counts, Jennifer M Date: 08/16/2016 A DISABLED VETERAN is 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 (b) a person who is discharged or released from active duty because of a service-connected disability. A RECENTLY SEPARATED VETERAN is any verteran who was discharged or released from active duty in the U.S. military, ground, naval, or air service within the last three years. AN ACTIVE DUTY WARTIME OR CAMPAIGN BADGE VETERAN is 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. If you would like more information on campaigns or expeditions for which a campaign badge has been authorized, please visit: https://www.opm.gov/policy-data-oversight/veterans-services/vet-guide/. AN ARMED FORCES SERVICE MEDAL VETERAN is 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. 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. This information is being requested on a voluntary basis and will be kept confidential as required by law. Refusal to provide the requested information will not subject you to any adverse treatment.

Please select one of the options below *

I am a protected veteran
I am not a protected veteran
I choose not to self identify

Voluntary Self-Identification of Disability

Form CC-305 OMB Control Number 1250-0005 Expires 1/31/2017 Why are you being asked 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.i 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 all of 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: - Autism - Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, or HIV/AIDS - Blind or low vision - Cancer - Cardiovascular or heart diseases - Celiac disease - Cerebral Palsy - Deaf or hard of hearing - Depression or anxiety - Diabetes - Epilepsy - Gastrointestinal disorders, for example, Crohn's Disease, or irritable bowel syndrome - Intellectual disability - Missing limbs or partially missing limbs - Nervous system condition for example, migraine headaches, Parkinson's Disease, or Multiple Sclerosis (MS) - Psychiatric condition, for example, bipolar disorder, schizophrenia, PTSD or major depression

Please select one of the options below *

Yes, I have a disability, or have a history/record of having a disability
No, I don't have a disability, or a history/record of having a disability
I do not wish to answer

Reasonable Accommodation Notice

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. Examples of reasonable accommodation 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. i 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. This Company is an Equal Opportunity Employer, and does not discriminate on the basis of race, gender, ethnicity, religion, national origin, age, disability, veteran status, or on any other basis prohibited by law. Information on race, gender and national origin will only be used for statistical and recordkeeping purposes, and will not be used in making any employment decisions. All information provided will be kept separate from your expression of interest. Providing this information is strictly voluntary, and you will not be subjected to any adverse action or treatment if you choose not to provide this information. If you do not choose to answer these questions, we ask that you select "Decline to Identify" for each question. Thank you for your voluntary cooperation.

Applicant Statement

I certify that all information I have provided in order to apply for and secure work with this employer is true, complete and correct. I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational situations and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me. I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state or federal law. I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application. If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate any employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer's president. I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard. Mandatory Employer Disclosures: Notice to Maryland applicants: UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND,AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT,THAT AN INDIVIDUAL SUBMIT TO OR TAKE A LIE DETECTOR OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $100. Notice to Massachusetts applicants: It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability. This Company does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding an applicant from consideration for employment on the basis of his or her sex, race, color, religion, national origin, genetic information, citizenship, age, disability, or any other protected status under applicable federal, state, or local law. This Company likewise does not tolerate harassment based on sex, race, color, religion, national origin, genetic information, citizenship, age, disability, or any other protected status. Examples of prohibited harassment include, but are not limited to, unwelcome physical contact, offensive gestures, unwelcome comments, jokes, epithets, threats, insults, name-calling, negative stereotyping, possession or display of derogatory pictures or other graphic materials, and any other words or conduct that demean, stigmatize, intimidate, or single out a person because of his/her membership in a protected category. Harassment of our employees is strictly prohibited, whether it is committed by a manager, coworker, subordinate, or non-employee (such as a vendor or customer). The Company takes all complaints of harassment seriously and all complaints will be investigated promptly and thoroughly. I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer's service, whenever it is discovered.

Signature of Applicant *

Clear Signature

Date

Employment Application

Employment History

Employer Information #1

Employer Information #2

Employer Information #3

Employer Information #4

Extra

Skills and Qualifications

Educational Background

School #1

School #2

School #3

School #4

References

List #1

List #2

List #3

Related Information

Voluntary Self-Identification of Race/Ethnicity

Voluntary Self-Identification of Gender

Voluntary Self-Identify As A Protected Veteran

Voluntary Self-Identification of Disability

Reasonable Accommodation Notice

Applicant Statement

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