Employment Application

We consider applicants for employment without regard to race, color, religion, creed, gender, national origin, age, disability or any other factor whose consideration is prohibited by applicable law.

First Name(Required)

Last Name(Required)

Middle Name(Required)

Address(Required)

City(Required)

State(Required)

Zip(Required)

Telephone 1(Required)

Telephone 2

Telephone 3

E-mail Address

Position(s) Applied For

Material Handler

Paint Yard Helper/Clean-up

Welder

Maintenance

Painter

Machine Operator

Fitter

Quality Control

Maintenance

Are you able to perform the essential functions of the position?(Required)

Yes

No (You may answer “yes” if reasonable accommodations may be required.)

Who referred you to the Company

Walk-in

inquiry

Agency

Friend

Relative

Other (If other please specify)

If Other

Date available for work(Required)

Desired Hourly Wage(Required)

Are you available to work overtime if required?

Yes

Are you available to work full-time?(Required)

Yes

Which shifts would you prefer?

1st: 6am-2:30pm

2nd: 2:30pm-11pm

No preference

If under 18 years of age, can you provide proof of your eligibility to work?

Yes

Can you travel if a job requires it?

Yes

Have you ever been convicted of a misdemeanor?(Required)

Yes

Have you ever been convicted of a felony?(Required)

Yes

A misdemeanor and/or felony conviction does not disqualify you from being offered employment.

Have you ever been employed with us before?(Required)

Yes

If yes, give date

Have you ever filled an application with us before?(Required)

Yes

If yes, give date(s)

List any friends / relatives employed by the company

List any affiliations with the Company's competitors, subcontractors, suppliers or vendors

Are you legally eligible to work in the US? (Note: Verification will be required upon hire)(Required)

Yes

Education

High School

Name

Location

Years Completed

Undergraduate College

Name

Location

Years Completed

Course of Study

Degree

Graduate / Professional

Name

Location

Years Completed

Course of Study

Degree

Post Graduate, Business, Technical, Other

Name

Location

Years Completed

Course of Study

Degree

Professional Certificates & Licenses

Name

From

Date Completed

Work Experience

Employer #1

Employer Name

Job Title

Start Date

End Date

Work Performed

Address

Phone

Supervisor

Hourly Rate/Salary

May we contact this employer?

Yes

Reason for Leaving

Employer #2

Employer Name

Job Title

Start Date

End Date

Work Performed

Address

Phone

Supervisor

Hourly Rate/Salary

May we contact this employer?

Yes

Reason for Leaving

Employer #3

Employer Name

Job Title

Start Date

End Date

Address

Phone

Supervisor

Hourly Rate/Salary

May we contact this employer?

Yes

Reason for Leaving

Employer #4

Employer Name

Job Title

Start Date

End Date

Address

Phone

Supervisor

Hourly Rate/Salary

May we contact this employer?

Yes

Reason for Leaving

List professional, trade, business or civic activities and offices held. You may exclude anything that would directly or indirectly disclose race, color, religion, sex, national origin or any other protected classification.

Have you ever been discharged or asked to resign from a prior position with any employer? If yes, please explain the circumstances.

Describe any specialized training, apprenticeships or skills you possess, including any job related training in military.

Personal/ Professional References (Do not list former employers or relatives.)

Name

Occupation

Phone Number

(Optional) Voluntary Self-Identification as a Protected Veteran.
This Company 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). VEVRAA requires Government contractors to take affirmative action to employ and advance in employment protected veterans.

Would you answer a question concerning your veteran status?

Yes

Voluntary Self-Identification as a Protected Veteran
Why are you being asked to complete this form, to help us measure the effectiveness of our outreach and recruitment efforts of veterans, we are asking you to tell us if you are a veteran covered by VEVRAA. Completing this form is completely voluntary, but we hope you fill it out. Any answer you give will be kept private and will not be used against you in any way. 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.

How Do You Know if You Are a Veteran Protected by VEVRAA?
Contrary to the name, VEVRAA does not just cover Vietnam Era veterans. It covers several categories of veterans from World War II, the Korean conflict, the Vietnam era, and the Persian Gulf War which is defined as occurring from August 2, 1990 to the present. If you believe you belong to any of the categories of protected veterans please indicate by checking the appropriate box below. The categories are defined on the next page (below) and explained further in an “Am I a Protected Veteran?” infographic provided by OFCCP.

Veteran Status

“Protected” veterans include the following categories: (1) disabled veterans; (2) recently separated veterans; (3) active-duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These categories are defined below.

1. 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 service-connected disability.
2. A “recently separated veteran” means any veteran during the three-year 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.
3. 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.
4. 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.

If you are a disabled veteran, please complete the following application question concerning your disability.

(Optional) Voluntary Self-Identification of Disability.
This Company is a Government contractor subject to Section 503 of the Rehabilitation Act of 1973, as amended (Section 503). Section 503 requires Government contractors to take affirmative action to employ and advance in employment individuals with disabilities.

Would you answer a question concerning your disability status?

Yes

Voluntary Self-Identification of Disability

Why are you being asked to complete this form? We are a federal contractor or subcontractor required by law to provide equal employment opportunity to qualified people with disabilities. We are also required to measure our progress toward having at least 7% of our workforce be individuals with disabilities. To do this, we must ask applicants and employees if they have a disability or have ever had a disability. Because a person may become disabled at any time, we ask all of our employees to update their information at least every five years.

Identifying yourself as an individual with a disability is voluntary, and we hope that you will choose to do so. Your answer will be maintained confidentially and not be seen by selecting officials or anyone else involved in making personnel decisions. Completing the form will not negatively impact you in any way, regardless of whether you have self-identified in the past. For more information about this form or the equal employment obligations of federal contractors under Section 503 of the Rehabilitation Act, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

How do you know if you 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 disease • 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.

Disability

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APPLICANT’S CERTIFICATION AND AUTHORIZATION

READ CAREFULLY

I affirm that all of the above information is true, correct and complete. I understand that any information provided by me above and/or in connection with my application for employment that is found to be false, incomplete or misrepresented in any respect will cancel further consideration of this application or subject me to immediate discharge from the Company whenever it is discovered. I believe that information concerning my performance as an employee, as well as information concerning my personal habits, conduct, deportment, as well as the information outlined hereinabove; will assist me in obtaining employment with the Company. Therefore, in consideration for the Company’s act of considering me for employment, I hereby agree to release and hold harmless the Company, together with its officers, agents, employees, affiliated corporations, subsidiaries, successors and assigns, from any and all liability in any way related to the investigation of my suitability for employment with the Company, including, but not limited to, any liability relating to contact and/or discussions with any of my employers, relatives, and/or acquaintances (past and/or present.) Moreover, I specifically authorize any person (natural or otherwise) to make full response to any inquiry in connection with my application for employment with the Company, and I release any such persons from all liability arising there from. I understand and acknowledge that in the event I am employed by the Company, my employment is not for any specific length of time but, rather, is of an “at-will” nature, which means that I may resign at any time and the Company may terminate my employment at any time with or without cause. I understand that no present or future employee handbook, policy manual, work rules or publication constitutes an employment agreement or contract. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is acknowledged in writing signed by both me and an authorized executive of the Company.

I agree(Required)