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Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Available Start Date *

MM

DD

YYYY

Do you have any family/relatives working for this company? *

Yes (If yes, please explain in the comments below.)

No

Have you ever worked for this company? *

Yes (If yes, please explain in the comments below.)

No

Are you a citizen of the United States? *

Yes

No

High School Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Did you graduate from high school? *

Yes

No

Did you graduate from college/university?

Yes

No

Did you graduate from other school?

Yes

No

Reference #1 Full Name *

First Name

Last Name

Reference #1 Phone *

(###)

###

####

Reference #2 Full Name *

First Name

Last Name

Reference #2 Phone *

(###)

###

####

Reference #3 Full Name

First Name

Last Name

Reference #3 Phone

(###)

###

####

Current Company Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Current Company Phone

(###)

###

####

May we contact your current supervisor for a reference?

Yes

No

Company Phone #1

(###)

###

####

May we contact Supervisor #1 for a reference?

Yes

No

Company Phone #2

(###)

###

####

May we contact Supervisor #2 for a reference?

Yes

No

Company Phone #3

(###)

###

####

May we contact Supervisor #3 for a reference?

Yes

No

Do you choose to complete this survey?

It is the policy of this organization to provide equal employment opportunity to all qualified applicants for employment without regard to race, color, religion, national origin, sex, age, veteran status, or disability. Submitting the information below is voluntary and in no way affects the decision regarding your application for employment. This form is confidential and will be maintained separately from your application form.

Yes (answer any or all of the following questions as desired)

No (scroll to the bottom of this form to submit your completed application)

Sex

Male

Female

Hispanic or Latino

A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race

Yes

No

NOT Hispanic or Latino

White - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa

Black or African American - A person having origins in any of the black racial groups of Africa

Native Hawaiian or Other Pacific Islander - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific island

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

American Indian or Alaskan Native - A person having origins in any of the original peoples of North and South America, including Central America, and who maintain tribal affiliation or community attachment

Two or more races (NOT Hispanic or Latino) - All persons which identify with more than one of the above five races

Do not wish to specifiy - All persons not wishing to self-identify race/ethnicity

Check all that apply

Disabled Veteran - A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or a person who was discharged or released from active duty because of a service-connected disability.

Recently Separated Veteran - Any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.

Active Duty Wartime or Campaign Badge Veteran - A veteran 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 under the laws administered by the Department of Defense.

Armed Forces Service Medal Veteran - A veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

Other - Please explain in the comments below.

Not Applicable

Disability Status** (check below if applicable)

**According to 41 CFR 60-741.42, there are only two circumstances when an employer may ask a disabled applicant to self-identify on a pre-offer basis: 1) The invitation is made when the contractor actually is undertaking affirmative action for individuals with disabilities at the pre-offer stage; or 2) The invitation is made pursuant to a Federal, State or local law requiring affirmative action for individuals with disabilities.

Individual with Disabilities - A person has a disability if they have a physical or mental impairment which substantially limits one or more major life activities; has a record of such impairment; or is regarded as having such impairment. A handicap is "substantially limiting" if it is likely to cause difficulty in securing, retaining, or advancing in employment.