Job Application 1Step 12Step 23Step 34Step 45Step 56Step 67Step 78Step 81/8Step 1 Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department. Name * Social Security # * Address * Zip * Telephone * Mobile/Other Phone # * E-mail Address * Position(s) Applied For * Date of Application * Referral Source (Please check the appropriate category and name the source.) Walk-In Employee Advertisement Company's Website Government Employment Agency School Job Fair Staffing Agency Other Internet Other If necessary, best time to call you at home is.. May we contact you at work? YesNo If yes, work number and best time to call: If you are under 18 and it is required, can you furnish a work permit? N/AYesNo If No, please explain Have you submitted an application here before? YesNo If yes, give date(s) and position(s) Have you even been employed here before? YesNo If yes, give date(s) From To Are you legally eligible for employment in this country? YesNo Date available for work What is your desired salary range or hourly rate of pay. Type of employment desired Full-TimePart-TimeEducational Co-opSeasonalTemporary Will you relocate if job requires it? YesNo Will you travel if job requires it? YesNo If they have been explained to you, are you able to meet the attendance requirements of the position? N/AYesNo Will you work overtime if required? YesNo If no, please explain Driver's license number required if driving may be required in the job for which you are applying? License State Have you ever been bonded? YesNo Answering "yes" to the following questions does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account. Have you ever pled "guilty" or "no contest" to, or been convicted of a crime? YesNo If yes, please provide date(s) and details Next Employment History Enter your most recent employment information and click "Add More". Continue adding all relevant work history. Employer Telephone # Dates Employed From To Street Address City State Starting job title/ final job title Immediate supervisor and title May we contact this reference? YesNoLater Why did you leave? Compensation (Starting) HourlySalary Compensation (Final) HourlySalary 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 the position? -+ Explain any gaps in your employment, other that those 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? YesNo If yes, please explain BackNext Skills and Qualifications Summarize any special training, skills, license and/or certificates that may assist you in performing the position for which you are applying. Computer Skills (check appropriate boxes, include software titles and years of experience.) Word Processing Spreadsheet Presentation E-mail Internet Other Other Other BackNext Educational Background Starting with your most recent school attended, provide the following information. School (include City and State) Years Completed Education CompletedSelectDiplomaGEDDegreeCertificationOther Completed Description GPA Class Rank Major Minor -+ References List name and telephone 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. Name Title Relationship to You Telephone Numbers of Years Known -+ BackNext Applicant Statement I certify that all information I have provided in order to apply for and secure 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 institutions 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, it's 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 my employment at any time, with or without cause and 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. 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. DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement. Signature of Applicant Date BackNext ACCUTECH INTERNATIONAL TERMS AND CONDITIONS OF EMPLOYMENT I UNDERSTAND AND AGREE THAT: 1. ANY MATERIAL MISREPRESENTATION OR DELIBERATE OMISSION OF A FACT IN MY APPLICATION MAY BE JUSTIFICATION FOR REFUSAL OF OR, IF EMPLOYED, TERMINATION FROM EMPLOYMENT. 2. I GRANT ACCUTECH THE RIGHT TO MAKE A THOROUGH INVESTIGATION OF MY ENTIRE WORK HISTORY AND TO VERIFY ALL DATA GIVEN IN MY APPLICATION FOR EMPLOYMENT, RELATED PAPERS OR ORAL INTERVIEWS. I RELEASE FROM LIABILITY ANY PERSON GIVING OR RECEIVING ANY SUCH INFORMATION. I UNDERSTAND THAT ANY DEROGATORY INFORMATION DISCOVERED AS A RESULT OF THIS INVESTIGATION MAY PREVENT MY BEING HIRED OR, IF HIRED, COULD RESULT IN IMMEDIATE DISMISSAL. ALTHOUGH MANAGEMENT MAKES EVERY EFFORT TO ACCOMMODATE INDIVIDUAL PREFERENCES, BUSINESS NEEDS MAY AT TIMES MAKE THE FOLLOWING CONDITIONS MANDATORY: • OVERTIME • A ROTATING WORK SCHEDULE • WORK ASSIGNMENT AT MORE THAN ONE LOCATION, OR • A WORK SCHEDULE OTHER THAN OUR STANDARD SCHEDULED WORK WEEK. 4. MY JOB DUTIES AND RESPONSIBILITIES AS STATED IN THE JOB DESCRIPTION MAY BE REVISED AND UPDATED AS THE NEED ARISES. THIS REVISION IS NECESSARY BECAUSE OF THE CONSTANTLY CHANGING TECHNOLOGY, REGULATIONS AND SERVICES OFFERED BY ACCUTECH. I FURTHER UNDERSTAND THAT THE JOB DESCRIPTION IS NOT ALL INCLUSIVE AND I WILL PERFORM OTHER REASONABLY RELATED BUSINESS DUTIES ASSIGNED BY MANAGEMENT. 5. THIS IS NOT A CONTRACT. Date Applicant Signature BackNext ACCUTECH INTERNATIONAL DISCLOSURE OF USE OF CONSUMER REPORTS FOR EMPLOYMENT PURPOSES AS PART OF THE PROCESS OF DETERMINING YOUR ELIGIBILITY FOR CURRENT OR FUTURE EMPLOYMENT OPPORTUNITIES, ACCUTECH MAY OBTAIN “CONSUMER REPORTS” CONTAINING INFORMATION FROM “CONSUMER REPORTING AGENCIES” ABOUT SUCH MATTERS AS YOUR CREDITWORTHINESS, CREDIT HISTORY, CHARACTER, GENERAL REPUTATION, PERSONAL CHARACTERISTICS, OR MODE OF LIVING. IN SOME CIRCUMSTANCES, WE MAY OBTAIN AN “INVESTIGATIVE CONSUMER REPORT”, WHICH IS A SPECIAL KIND OF CONSUMER REPORT IN WHICH INFORMATION ON YOUR CHARACTER, GENERAL REPUTATION, PERSONAL CHARACTERISTICS, OR MODE OF LIVING IS OBTAINED THROUGH PERSONAL INTERVIEWS WITH YOUR NEIGHBORS, ASSOCIATES OR OTHERS WHO HAVE KNOWLEDGE ABOUT YOU. BackNext ACCUTECH INTERNATIONAL AUTHORIZATION OF CONSUMER REPORTS FOR EMPLOYMENT PURPOSES I HAVE REVIEWED A DISCLOSURE OF USE OF CONSUMER REPORTS FOR EMPLOYMENT PURPOSES AND I AUTHORIZE ACCUTECH TO OBTAIN ANY CONSUMER REPORTS IT MAY WISH TO USE NOW OR IN THE FUTURE FOR EMPLOYMENT PURPOSES (INCLUDING DECISIONS ON HIRING, PROMOTION, TRANSFER, ETC.). Date Applicant Signature Back
