Application For Employment


EQUAL OPPORTUNITY EMPLOYER. It is our policy to abide by all federal, state and local laws prohibiting employment discrimination based solely on a person's race, color, religious creed, sex, national origin, ancestry, citizenship status, pregnancy, childbirth, physical disability, mental disability, mental disability, age, military status or status as a Vietnam-era or special disabled veteran, marital status, registered domestic partner or civil union status, gender (including sex stereotyping and gender identity or expression), medical condition (including, but not limited to, cancer related or HIV/AIDS related), genetic information, sexual orientation, or any other protected status except where a reasonable, bona fide occupational qualification exists.

How did you hear about the position for which you are applying?
If you were referred by one of our employees, please provide their name:


Full-TimePart-TimeTemporary
Are you subject to any type of agreement with a current or former employer or entity that would restrict your ability to work at our company (e.g., non-compete, confidentiality, non-disclosure)?
YesNo

Education & Training

School Name
City and State
Degree/Diploma Major Course of Study
Degree Received?
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
*Only list colleges or universities accredited by the Department of Education (DOE). The DOE maintains a database of accredited institutions at ope.ed.gov/accreditation

List course work undertaken or degree/diploma received from an unaccredited college, as well as any other education, training, special skills or certificates/license that you possess related to the job:

If you are applying for a position which involves driving a motor vehicle in the course and scope of the employment duties, please indicate whether you have a valid driver's license in this state.
YesNo

General Information

Can you, after employment, submit verification of your legal right to work in the United States? YesNo
Are you 16 years old or over? NoYes
> Age 161718 or over
Were you previously employed at our company?
YesNo
If yes, give dates
Can you perform the essential functions of the job? YesNo
List any relatives working for our company:

Employment History

List all work experience beginning with the present or most recent job.)

Part TimeFull Time
May we contact? YesNo

Part TimeFull Time
May we contact? YesNo

Part TimeFull Time
May we contact? YesNo

CRIMINAL RECORD INFORMATION

(Instructions for answering the next two questions below):

  1. All Applicants. Do not include convictions that were sealed, eradicated, erased, annulled by a court, expunged, pardoned, or deferred and
    withdrawn.
  2. District of Columbia, Illinois, and Rhode Island Applicants. Do not respond to the second question (regarding pending charges).
  3. California Applicants. Do not include: a misdemeanor conviction for possession or transportation of a small amount of marijuana (28.5 grams or
    less) if the conviction is more than two (2) years old; participation in any pretrial or post trial diversion program for drug or alcohol rehabilitation;
    or a misdemeanor conviction for which probation was successfully completed or otherwise discharged and the case was judicially dismissed.
  4. Colorado Applicants. Exclude information involving any record of civil or military disobedience unless such matters resulted in a plea of guilty or
    a conviction by a court of competent jurisdiction.
  5. Connecticut Applicants. You are not required to disclose the existence of any arrest, criminal charge, or conviction, the records of which have
    been erased. Criminal records subject to erasure are: records pertaining to a finding of delinquency or the fact that a child was a member of a family
    with service needs; an adjudication as a youthful offender; a criminal charge that has been dismissed or nulled (not prosecuted); a criminal charge
    for which the person was found not guilty; or a conviction for which the offender received an absolute pardon. Any person whose criminal records
    have been erased is deemed to have never been arrested within the meaning of the law as it applies to the particular proceedings that have been
    erased, and may so swear under oath.
  6. Hawaii Applicants. Do not answer the following two questions.
  7. Massachusetts Applicants. Do not answer the following two questions.
  8. Michigan Applicants. Regarding pending charges, limit your response to felony offenses.

  1. Convictions/Pleas. In the past ten (10) years, have you ever been convicted of, or pled guilty or no contest to, any criminal offense other than any applicable exceptions listed above?
YesNo
  1. Pending Changes. Have you been arrested for any matters for which you are now out on bail or on your own recognized pending trial?
YesNo

  1. City of Philadelphia (Pennsylvania) Applicants. Do not respond to the first question (regarding convictions/pleas).
  2. Utah Applicants. Regarding convictions, limit your response to felony convictions. Do not respond to the second question (regarding
    pending charges).

ADDITIONAL INFORMATION

BUSINESS REFERENCES

(List three individuals, in addition to listed employment references, known to you for at least three years):

Please include any other information you think would be helpful to us in considering you for employment, such as additional work experience, articles/books published, activities, honors received, etc. You may omit all information that would indicate age, sex, sexual orientation, race, religion, color, national origin, or disability.

Please read the following statement carefully.

I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete to the best of my knowledge. I also agree that falsification or significant omission of information requested in this application or in the application process may disqualify me from further consideration for employment and may be considered justification for dismissal if discovered at a later date.

I authorize all persons listed above (and on the accompanying resume, if any) to give employer and/or any service providers any and all information concerning my previous employment and education and any pertinent information they may have, personal or otherwise, and release all parties, such persons and employer and/or any service providers, from liability for any damage that may result from furnishing same to employer and/or any service providers.

I understand that employer will provide workers' compensation insurance coverage for its employees. In the event of an injury in the workplace, I agree that my sole remedy lies in coverage under employer's workers' compensation insurance policy.

If employed by employer, I agree to abide by the policies and procedures of employer. I further understand that my employment can be terminated, with or without cause or notice, at any time, at the discretion of employer or myself.

I understand that employer may obtain a consumer and/or investigative consumer report for employment purposes that may include information regarding prior employment, work experience and performance, reasons for employment termination, and information as to character, general reputation, personal characteristics, or mode of living. The report may also contain a records check of driving, criminal, credit, education, degrees, professional licenses and/or certification records depending on the position. By signing this application, I authorize the procurement of a consumer and/or investigative consumer report by employer and/or any service providers as part of the pre-employment background investigation and if hired, at any time during my employment. California Applicants: I further understand that employer and/or any service providers may obtain Public Records about me as part of an internal background investigation and that I may waive my right to receive a copyof such Public Records by checking this box:

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.

I understand and agree that, subject to applicable law, I may be required to take a drug and alcohol screening test. I hereby give my voluntary consent for a blood and/or urine sample to be collected from me and submitted for testing. I also consent to the release of the test results to employer and/or any service providers. I understand that any positive drug or alcohol result may preclude my employment.