Application for Employment

An Equal Opportunity Employer

We are an affirmative action employer and that age 40 and over, color, disability, gender identity, genetic information, military or veteran status, national origin, race, religion, sex, sexual orientation or any other applicable status protected by state or local law, are not taken into account in any employment decision.

Answer each question fully and accurately. No action can be taken on this application until you have answered all questions. In reading and answering the following questions, be aware that none of the questions are intended to imply illegal preferences or discrimination based upon non-job-related information.

Job Applied for:*

What type of employment are you seeking:*

Full-time
Part-time
Temporary

When could you start work?

General Information

Name*

First Middle Last

Cell Phone Number*

Email

Address

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

Are you 18 years of age or older?*

Yes
No

(If you are hired, you may be required to submit proof of age.)

If hired, you will be required to furnish proof of your eligibility to work in the U.S.

Have you ever applied here before?*

Yes
No

Were you ever employed here?*

Yes
No

If yes, when?

If employed, do you expect to be engaged in any additional business or employment outside of our job?*

Yes
No

If yes, give details

Education

High School or GED (list name and address)

Number of Years Completed in High School

Did you graduate and get a diploma?

Yes
No

College or University Name and Address

Subjects Studies in College

Number of Years Completed

Diploma/Degree/Certificate

Vocational or Technical School Name and Address

Subjects Studies in Vocational or Tech School

Number of Years Completed

Diploma/Degree/Certificate

Special Skills

What skills or additional training do you have that are related to the job for which you are applying?

For Driving Jobs Only: Do you have a valid driver’s license?

Yes
No

Driver’s License Number

Class of License

State Licensed in

Have you had your driver’s license suspended or revoked in the last 3 years?

Yes
No

If yes, give details:

Additional Skills

List professional, trade, business or civic activities and offices held. (Exclude labor organizations and memberships which reveal race, color, religion, national origin, sex, age, disability, genetic information or other protected status.)

Work History

List names of employers in consecutive order with present or last employer listed first. Account for all periods of time including military service and any periods of unemployment. If self-employed, give firm name and supply business references.

Note: A job offer may be contingent upon acceptable references from current and former employers.

First Employer Name, Address and Telephone

Your Job Title

Employed From

Employed To

Starting Pay

Final Pay

Duties

Reason for leaving

Supervisor(s)

Second Employer Name, Address and Telephone

Your Job Title

Employed From

Employed To

Starting Pay

Final Pay

Duties

Reason for leaving

Supervisor(s)

Third Employer Name, Address and Telephone

Your Job Title

Employed From

Employed To

Starting Pay

Final Pay

Duties

Reason for leaving

Supervisors

Fourth Employer Name, Address and Telephone

Your Job Title

Employed From

Employed To

Starting Pay

Final Pay

Duties

Reason for leaving

Supervisors

References

Have you worked or attended school under any other names?

Yes
No

If yes, give names:

Are you presently employed?

Yes
No

If yes, whom do you suggest we contact?

Have you ever been fired from a job or asked to resign?

Yes
No

If yes, please explain:

Give three professional references, not relatives or former employers.

Reference #1

Address

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

Phone

Reference #2

Address

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

Phone

Rerference #3

Address

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

Phone

THIS ORGANIZATION PARTICIPATES IN E-VERIFY

This employer participates in E-Verify and will provide the federal government with your Form I-9 information to confirm that you are authorized to work in the U.S.

If E-Verify cannot confirm that your are authorized to work, this employer is required to give you written instruction and an opportunity to contact Department of Homeland Security (DHS) or Social Security Addminstration (SSA) so you can begin to resolve the issue before the employer can take any action against you, including terminating your employment.

Employers can only use E-Verify once you have accepted a job offer and completed the Form I-9.

E-Verify Works for Everyone

For more information on E-Verify, or if you believe that your employer has violated it’s E-Verify responsibilities, please contact DHS.

888-897-7781

dhs.gov/e-verify

I have read, understand, and by my signature consent to these statements.

Signed (Type your name to authorize signature)

AFFIDAVIT,CONSENT AND RELEASE

PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING

I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date.

I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employers, and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements.

I understand I may be required to successfully pass a drug screening examination. I hereby consent to a pre- and/or post-employment drug screen as a condition of employment, if required.

I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying.

I UNDERSTAND THAT THIS APPLICATION, VERBAL STATEMENTS BY MANAGEMENT, OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE AN EXPRESS OR IMPLIED CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. ONLY THE PRESIDENT OF THE ORGANIZATION HAS THE AUTHORITY TO ENTER INTO AN AGREEMENT OF EMPLOYMENT FOR ANY SPECIFIED PERIOD AND SUCH AGREEMENT MUST BE IN WRITING, SIGNED BY THE PRESIDENT AND THE EMPLOYEE. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT REASON AND WITH OR WITHOUT NOTICE.

I have read, understand, and by my signature consent to these statements.

Signed (Type your name to authorize signature)

Would you like to submit your resume?

Yes
No thank you

Upload Your Resume

This application for employment will remain active for a limited time.

Ask the organization’s representative for details.

EEO-1 Self-Identification Form

The employer is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, the employer invites employees to voluntarily self-identify their race and ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information will be kept confidential and will only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual.

(If also a federal contractor/subcontractor – add this clause): As employers/government contractors, we also comply with government regulations including but not limited to affirmative action responsibilities as required under Executive Order 11246, Section 503 of the Rehabilitation Act of 1973, section 4212 of the Vietnam Era Veterans Readjustment Act of 1974 and Veterans Employment Opportunities Act (VEOA) of 1998.

This data is for periodic government reporting and will be kept in a Confidential File separate from the Application for Employment.

Referral Source:

Advertisement
Friend
Relative
Walk-In
Employment Agency
Company Website
Other

EEO-1 Survey

If you wish to be identified, please sign below and complete the survey:

Signed (Type your name to authorize signature)

Check One:

Male
Female

Ethnicity

Are you Hispanic or Latino?

No, I am not Hispanic or Latino.
Yes, I am Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race.

Race – IMPORTANT - Only complete this section if you checked “No, I am not Hispanic or Latino” in the Ethnicity section above:

What is your race? Select ONE of the following categorie(s):

White – A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.
Black or African American – A person having origins in any of the Black racial groups of Africa.
American Indian/Alaskan Native – A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment.
Asian – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
Native Hawaiian or Other Pacific Islander – A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Two or More Races – All persons who identify with more than one of the above five races.

(If federal contractor/subcontractor with affirmative action obligations – add the following section) Check if the following is applicable:

Veteran – As defined under one or more of the following:

Yes I am a veteran

• Served on active duty for a period of more than 180 days, and any part of which occurred between August 5, 1964 and May 7, 1975 and were discharged or released other than dishonorably; or,

• As discharged or released from active duty for a service connected disability if any part of the active duty was performed between August 5, 1964 and May 7, 1975; or

• 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 (such as The Persian Gulf, El Salvador, Grenada, Lebanon, Panama, Southwest Asia, Haiti, Somalia & Bosnia); or

• One who served on active duty in the U.S. military, ground, naval or air service during the one-year period beginning on the date of discharge or release from active duty (recently separated veteran).

Voluntary Self-Identification of Disability

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.

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:

Blindness
Deafness
Cancer
Diabetes
Epilepsy
Autism
Cerebral palsy
HIV/AIDS
Schizophrenia
Muscular dystrophy
Bipolar disorder
Major depression
Multiple sclerosis (MS)
Missing limbs or partially missing limbs
Post-traumatic stress disorder (PTSD)
Obsessive compulsive disorder
Impairments requiring the use of a wheelchair
CIntellectual disability (previously called mental retardation)

Please check one of the boxes below:

YES, I HAVE A DISABILITY (or previously had a disability)
NO, I DON’T HAVE A DISABILITY
I DON’T WISH TO ANSWER

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.

Incomplete information may result in a report delay. Orders received after three p.m. will be treated as next day business.

FAIR CREDIT REPORTING ACT

DISCLOSURE REGARDING BACKGROUND INVESTIGATION

As an applicant for employment or a current employee of ESSMetron, you are a consumer with rights under the Fair Credit Reporting Act. In the event any of the following circumstances exist, ESSMetron, choose to obtain and use information contained in either a consumer report or an investigative consumer report from a consumer reporting agency about you when: (1) considering your application for employment, (2) making a decision whether to offer you employment, (3) deciding whether to continue your employment (if you are hired), or (4) making other employment related decisions directly affecting you.

Our consumer reporting agency is Mountain States Employers Council, Inc. at PO Box 539, Denver, CO 80201, toll free 800.884.1328, which, for monetary fees, dues, or on a cooperative nonprofit basis, regularly assembles or evaluates consumer information on consumers for the purpose of furnishing consumer reports to others, such as ESSMetron.

A consumer report means any written, oral or other communication of any information by a consumer reporting agency bearing on your character, general reputation, personal characteristics, or mode of living which is used or expected to be used or collected in whole or in part for the purpose of serving as a factor in establishing your eligibility for employment purposes.

An investigative consumer report means a consumer report or portion thereof in which information on your character, general reputation , personal characteristics , or mode of living is obtained through personal interviews with your neighbors , friends, or associates reported on or with others with whom you are acquainted or who may have knowledge concerning any such items of information.

In the event an investigative consumer report is prepared, you may request additional disclosures regarding the nature and scope of the investigation requested as well as a written summary of your rights under the Fair Credit Reporting Act.

AUTHORIZATION REGARDING BACKGROUND INVESTIGATION

I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of these documents.

ESSMetron ("the Company") may obtain information about you for employment purposes from the following consumer reporting agency ("the Agency"), Mountain States Employers Council, Inc., PO Box 539, Denver, CO 80201, toll free 800-884-1328.

By signing below, I hereby voluntarily authorize ESSMetron, to obtain either a consumer report or an investigative consumer report about me from a consumer reporting agency and to consider this information when making decisions regarding my employment at ESSMetron. I understand that I have rights under the Fair Credit Reporting Act, including the rights discussed above.

I voluntarily authorize all persons, including current and former employers and supervisors, educational institutions, law enforcement agencies, motor vehicle departments, and municipal, state, and federal courts to release information they may have about me to ESSMetron. I understand that if I am employed by ESSMetron, this authorization shall remain in effect throughout my employment. This report may be delivered in either written or electronic form.

California applicants or employees only:

Please check this box if you would like to receive a copy of an investigative consumer report at no charge if one is obtained by the Company whenever you have a right to receive such a copy under California law. By signing below you also acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW.

Massachusetts, and New Jersey applicants or employees only:

You have the right to inspect and promptly receive a copy of any investigative consumer report requested by the Company by contacting the consumer reporting agency identified above directly.

Minnesota applicants or employees only:

You have the right, upon written request to the Agency, to receive a complete and accurate disclosure of the nature and scope of any consumer report. The Agency must make this disclosure within five days of receipt of your request or of the Company's request for the report, whichever is later. Please check the box if you wou Id Iike to receive a copy of a consumer report if one is obtained by the Company.

New York applicants or employees only:

You have the right to inspect and receive a copy of any investigative consumer report requested by the Company by contacting the consumer reporting agency identified above directly. By signing below, you also acknowledge receipt of Article 23-A of the New York Correction Law.

Oklahoma applicants or employees only:

Please check this box if you would like to receive a copy of any report if one is obtained by the Company.

Pennsylvania applicants or employees only:

By signing below you acknowledge that consideration of a criminal record will be tailored to the requirements of the job.

Washington applicants or employees only:

You have the right to receive a complete and accurate disclosure of the nature and scope of any investigative consumer report as well as a written summary of your rights and remedies under Washington law.

Social Security Number

xxx-xx-xxxx

Date of Birth

Signed (Type your name to authorize signature)

Phone

This field is for validation purposes and should be left unchanged.

Application for Employment

Welcome

New Application for Employment

Application for Employment

An Equal Opportunity Employer

General Information

Education

Special Skills

Work History

References

Give three professional references, not relatives or former employers.

THIS ORGANIZATION PARTICIPATES IN E-VERIFY

AFFIDAVIT,CONSENT AND RELEASE

EEO-1 Self-Identification Form

EEO-1 Survey

Voluntary Self-Identification of Disability

Why are you being asked to complete this form?

FAIR CREDIT REPORTING ACT

DISCLOSURE REGARDING BACKGROUND INVESTIGATION

AUTHORIZATION REGARDING BACKGROUND INVESTIGATION