Employment Application

The company is an equal opportunity employer. As such, we provide employment opportunities withoutregard to race, color, religion, national origin, gender, age, disability, veteran status, military service, or other characteristics protected by law.

"*" indicates required fields

Position Sought

Position Applied For*

Personal Information

Full Name*

First Name Middle Name Last Name

Other names by which you have been known and applicable dates

Address*

Street Address City State / Province / Region ZIP / Postal Code

Telephone*

E-mail*

Are you at least 18 years old?*

Yes

If you are under 18, can you furnish a work permit?*

Yes

Are you authorized to work in the U.S.?*

Yes

Do you now, or will you in the future, require sponsorship for employment visa status?*

Yes

Date you can start work*

MM slash DD slash YYYY

Position desired*

Full-time

Part-time

Temporary

Seasonal

Educational Co-Op

Shift availability*

Day

Evening

Night

Rotating

(check all that apply)

Day availability*

Mon

Tues

Wed

Thurs

Fri

Sat

Sun

(check all that apply)

Overtime availability*

Yes

Have you applied for employment with the company before?*

Yes

If so, when? Mention Date & Position*

Have you ever worked for the company before?*

Yes

If so, when? Mention Date & Position*

Employment History

Have you ever been involuntarily terminated or asked to resign from employment?*

Yes

If so, give the name of the employer, dates of employment, position held, name of supervisor, and reason for termination/resignation request:*

Have you ever been counseled, disciplined, terminated or asked to resign as a result of reported workplace harassment, fighting/assault, violation of safety rules, or other inappropriate condition?*

Yes

If so, give the name of the employer, date and description of incident*

Do you have any employment history to add?*

Yes

Employment history

Name of employer*

Position(s) held, job responsibilities, salary, supervisor and dates*

Address/phone number of location where you worked*

Reason for leaving*

Add more

Educational Background

Completed High School?*

Yes

High School Name & Location*

Years Completed*

Did You Graduate?

Yes

Degree*

Completed College?*

Yes

College Name & Location*

Years Completed*

Did You Graduate?

Yes

Degree*

Completed Trade School?*

Yes

Trade School Name & Location*

Did You Graduate?

Yes

Degree*

Completed Graduate School?*

Yes

Graduate School Name & Location*

Did You Graduate?

Yes

Degree*

References

(List 3. Do not list relatives, domestic partners, or former employers.)

References

Name*

Occupation*

Complete Address*

Phone number*

Dates known*

MM slash DD slash YYYY

Add Reference

Criminal History

Have you ever been convicted of (or pleaded guilty or no contest or paid a fine for) ANY criminal offense of ANY type whatsoever (this includes but is not limited to felonies, misdemeanors, DWI, hunting offenses, domestic violence, city or county ordinances)?*

Yes

If so, list all offense(s), date(s) of conviction/plea, county/city/state of conviction*

Professional Certifications

List all professional licenses, certifications, etc., that may be related to the position you are applying for and list dates issued and name of the organization granting the license, certification, etc.*

List and describe any special skills, second languages, or other training you have that may be related to your employment.*

Driving History

(If the position you seek requires you to drive a vehicle, please answer the following questions.)

Do you have a valid driver’s license?*

Yes

List state, number, and expiration date*

List all states from which you have held a driver’s license and dates held*

Has your driver’s license, permit, or privileges ever been suspended, revoked, or canceled?*

Yes

List state(s), date(s), and reason(s)*

Have you ever been denied a driver’s license, permit, or privilege to drive by a government agency or employer?*

Yes

List date(s), government agency(ies)/employer(s), and reason(s)*

Have you ever been charged with any traffic-related offenses?*

Yes

List all offense(s), date(s), location(s), and result(s)*

If the position you seek requires you to operate a commercial motor vehicle, please answer the following questions. Name of all employers for whom you operated a commercial motor vehicle during the past 10 years:

Note: Be sure that these employers, addresses, dates of employment, and reasons for leaving are identified in the employment history section of the application.

During the previous two years, have you had an alcohol test result of 0.04 alcohol concentration or greater?*

Yes

During the previous two years, have you had a verified positive controlled substance test result?*

Yes

During the previous two years, have you refused to take an alcohol or drug test?*

Yes

Important Information

I certify that the information provided on this application form, along with all other information I have provided to the company, is accurate and complete. I understand that any misrepresentations or omissions will be cause for not hiring me or for terminating my employment, once hired.

I understand that the company will undertake, and I authorize the company to undertake, any investigation it deems necessary in considering me for employment or, if hired, my continued employment. I expressly authorize any present or former employer; school, college, or university; utility company; credit or finance bureau; personal reference; chief law enforcement officer; any member of any local, state, or federal law enforcement agency; or any other person to give the company any information (written or oral) or records concerning me or my qualifications, employment (including but not limited to the reasons for my termination), credit, reputation, mode of living, education, or criminal record. I unconditionally release the company and its representatives and agents and all persons from whom they request information from any and all liability relating to such request for information or any information provided.

I understand that this application will be active only for the specific position identified above and only during the period the company is seeking to fill the current opening(s), and that any job offer, or if hired, my continued employment, may be conditioned upon a medical examination and/or alcohol or drug testing.

I understand that, if hired, my employment will be strictly at will. That means that my employment is for an indefinite period and that the company or I may terminate the employment at any time, for any or no reason, with or without notice or intermediate steps. I further understand that no verbal statements or statements in any company policy or procedure manual, employee handbook, or other document shall be construed to have altered the at-will nature of my employment. No company manager or representative shall be authorized to make any representations to the contrary.

Signature*

Date*

MM slash DD slash YYYY

By submitting this application, you agree that AppCAA may collect and use the information you provide for the purpose of processing your application. Submissions are sent securely by email to AppCAA staff and automatically deleted from our website 90 days after processing. For questions about how we handle your personal information, please contact us at mdockery@appcaa.org.