PERSONNEL SOLUTIONS PLUS Employment Application The Company is an equal opportunity employer and does not discriminate against any applicant or employee because of race, color, religion, sex, national origin, disability, age, or military or veteran status in accordance with federal law. In addition, The Company complies with applicable state and local laws governing non-discrimination in employment in every jurisdiction in which it maintains facilities. The Company also provides reasonable accommodation to qualified individuals with disabilities in accordance with applicable laws. TODAYS DATE PERSONAL INFORMATION LAST NAME: FIRST NAME: MIDDLE INITIAL: HOME PHONE: MOBILE PHONE: POSITION INFORMATION REFERRED BY: WALK-IN ADVERTISEMENT EMPLOYEE (Name: ) POSITION APPLIED FOR: DESIRED PAY: DATE AVAILABLE: ARE YOU UNDER 18 YEARS OF AGE: Yes No ARE YOU CURRENTLY AUTHORIZED TO WORK FOR ANY EMPLOYER IN THE UNITED STATES ON A FULL-TIME BASIS OR ONLY FOR YOUR CURRENT EMPLOYER? Full-Time Only for my current employer If no, can you furnish a Work Permit? Yes No WILL YOU NOW OR IN THE FUTURE REQUIRE SPONSORSHIP FOR EMPLOYMENT VISA STATUS (e.g. H-1B status)? Yes No Federal law requires that employers hire only individuals who are authorized to be lawfully employed in the United States. In compliance with these laws, the Company will verify the status of every individual offered employment through E-Verify. In this connection, all offers of employment are subject to verification of the applicant s identity and employment authorization, and it will be necessary for you to submit such documents as are required by law to verify your identification and employment authorization. ARE YOU CAPABLE OF PERFORMING THE ESSENTIAL FUNCTIONS OF THE JOB YOU ARE APPLYING WITH OR WITHOUT A REASONABLE ACCOMODATION? Yes No DRIVER S LICENSE INFORMATION TYPE OF LICENSE (CLASS): STATE: LICENSE NUMBER: PSPAPPLICATION0817 Page 1 of 6
EDUCATION INFORMATION NAME OF HIGH SCHOOL: 1 ADDRESS: DID YOU GRADUATE: Yes No TYPE OF CERTIFICATE: Diploma GED NAME OF COLLEGE: 2 ADDRESS MAJOR SUBJECT: DID YOU GRADUATE: Yes No TYPE OF DEGREE: NAME OF GRADUATE SCHOOL: 3 ADDRESS MAJOR SUBJECT: DID YOU GRADUATE: Yes No TYPE OF DEGREE: OTHER: (Vocational, Technical, etc.) 4 ADDRESS MAJOR SUBJECT: DID YOU GRADUATE: Yes No TYPE OF CERT./DEG. EMPLOYMENT INFORMATION - Complete for all full and part time employment, beginning with most recent, 7-year work history. (use blank page for additional entries) Massachusetts applications may include any verified work performed on a volunteer basis. COMPANY NAME: POSITION/TITLE: FROM TO SUPERVISOR NAME: SUPERVISOR TITLE/POSITION: TYPE OF BUSINESS: SUPERVISOR TELEPHONE NUMBER: BUSINESS TELEPHONE NUMBER: STARTING PAY: FINAL PAY: TERMINATION TYPE: REASON FOR TERMINATION: Voluntary Involuntary Other (Explain below) PSPAPPLICATION0817 Page 2 of 6
BRIEF DESCRIPTION OF MAJOR DUTIES: COMPANY NAME: POSITION/TITLE: SUPERVISOR NAME: FROM TO SUPERVISOR TITLE/POSITION: TYPE OF BUSINESS: SUPERVISOR TELEPHONE NUMBER: BUSINESS TELEPHONE NUMBER: STARTING PAY: FINAL PAY: TERMINATION TYPE: REASON FOR TERMINATION: Voluntary Involuntary Other (Explain below) BRIEF DESCRIPTION OF MAJOR DUTIES: COMPANY NAME: POSITION/TITLE: FROM TO SUPERVISOR NAME: SUPERVISOR TITLE/POSITION: TYPE OF BUSINESS: SUPERVISOR TELEPHONE NUMBER: BUSINESS TELEPHONE NUMBER: STARTING PAY: FINAL PAY: TERMINATION TYPE: REASON FOR TERMINATION: Voluntary Involuntary Other (Explain below) BRIEF DESCRIPTION OF MAJOR DUTIES: PSPAPPLICATION0817 Page 3 of 6
OTHER SKILLS INFORMATION Specify any other skills and proficiency levels. 1. 2. 3. 4. 5. AVAILABILITY INFORMATION OPEN AVAILABILITY (No restrictions)? Yes No MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY ADDITIONAL INFORMATION Unemployment Account for all periods of time, three months or more, between positions. FROMTO FROMTO FROMTO HOW DID YOU SPEND THIS TIME? HOW DID YOU SPEND THIS TIME? HOW DID YOU SPEND THIS TIME? ADDITIONAL INFORMATION - Background IN THE LAST SEVEN (7) YEARS, HAVE YOU BEEN CONVICTED OF OR HAVE YOU PLEADED GUILTY TO ANY FELONY OR MISDEMEANOR? (PLEASE EXCLUDE MINOR TRAFFIC OFFENSES AND CONVICTIONS WHICH HAVE BEEN SEALED, IMPOUNDED, ERASED, EXPUNGED, ANNULLED OR NOLLED) California applicants: In accordance with California Labor Code Sections 423.7 and 423.8, please do not disclose information regarding any misdemeanor convictions from marijuana-related offenses that are more than two years old or any other information regarding any pre-trial or post-trial diversion programs in which you have participated. Connecticut applicants need not disclose the existence of any arrest, criminal charge or conviction if such records have been erased pursuant to 46b-146, 54-142a, 54-760 of the Connecticut General Statutes; criminal records subject to erasure under the abovereferenced sections are recorded pertaining to a finding of delinquency or 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, a criminal charge for which the person has been found not guilty of a conviction for which the person received an absolute pardon; and any person whose criminal records have been erased pursuant to the above-referenced sections shall be deemed to never have been arrested within the meaning of the Connecticut General Statutes with respect to the proceedings which have been erased, and may never swear to this under oath. Georgia applicants should not disclose any information pertaining to convictions protected under the First Offenders Act. Hawaii applicants should not disclose any information in response to this question. Louisiana, Montana, and Utah applicants should only disclose information regarding felonies. Massachusetts applicants: An applicant for employment with a sealed record on file with the commissioner of probation may answer no record with respect to any inquiry herein relative to prior arrests, criminal court appearances or convictions. In addition, any applicant for employment may answer no record with respect to any inquiry relative to prior arrests, court appearances and adjudications in all cases of delinquency or as a child in need of services which did not result in a complaint transferred to the superior court for criminal PSPAPPLICATION0817 Page 4 of 6
prosecution. Please do not disclose first misdemeanor convictions for drunkenness, simple assault, speeding, minor traffic violations, affray, or disturbance of the peace or any misdemeanor conviction or release from incarceration that occurred more than 5 years before the date of this application (unless you have been convicted of any offense within the last 5 years). Montana and New Mexico applicants need not provide information beyond seven years prior to today s date. New York applicants should disclose information pertaining to youthful offender adjudications. Nevada applicants should only disclose information regarding misdemeanors that result in imprisonment or felonies. Washington applicants need not disclose a conviction that occurred more than ten years before the date of this application. NOTE: OTHER FACTORS WILL BE TAKEN INTO ACCOUNT SUCH AS THE NATURE OF THE OFFENSE, THE TIME THAT HAS PASSED SINCE THE CONVICTION AND THE TYPE OF JOB BEING SOUGHT, FURTHER, THIS INFORMATION WILL BE USED ONLY FOR JOB-RELATE PURPOSES AND ONLY TO THE EXTENT PERMITTED BY APPLICABLE LAW. Yes No If yes, please describe: REFERENCE INFORMATION - Please provide three employment references NAME: EMPLOYER: PHONE: 1 STREET ADDRESS: NAME: EMPLOYER: PHONE: 2 STREET ADDRESS: NAME: EMPLOYER: PHONE: 3 STREET ADDRESS: PSPAPPLICATION0817 Page 5 of 6
PLEASE READ CAREFULLY BEFORE SIGNING APPLICATION During the application process and, if hired, during employment, I agree to participate (if so requested by the Company and as not prohibited by applicable law) in testing to determine whether employees are under the influence of controlled drugs or illegal substances. Such tests or examinations will be performed by qualified professionals selected by the Company. My signature attests to the fact that the information that I have provided on my application, resume, given verbally, or provided on any other materials, is true and complete to the best of my knowledge and also constitutes authority to verify any and all information submitted on this application. I understand that any misrepresentation or omission of any fact in my application, resume or any other materials, or during any interviews, can be justification for refusal of employment, or, if employed, termination from the Company s employ. The Company or its agents may seek to verify the information on this application. As such, I hereby authorize the Company or its agents to contact any former employer or any representative of any other organization to which I have made reference in this application, and I hereby authorize said employer and/or representative to provide information to the Company on my behalf. I also affirm that I have not signed any kind of restrictive document creating any obligation to any former employer that would restrict my acceptance of employment with the Company in the position I am seeking. I understand that this application is not an employment contract for any specific length of time between the Company and me, and that in the event I am hired, my employment will be at will and either the Company or I can terminate my employment without cause and with or without notice at any time. Nothing contained in any handbook, manual, policy and the like, distributed by the Company to its employees is intended to or can create an employment contract, an offer of employment or any obligation on the Company s part. The Company may, at its sole discretion, hold in abeyance or revoke, amend or modify, abridge or change any benefit, policy practice, condition or process affecting its employees. I acknowledge that I have read all of the above statements, and that I understand all content. APPLICANT PRINT NAME DATE / / APPLICANT SIGN NAME PSPAPPLICATION0817 Page 6 of 6