Application for Employment – Aetna Bridge Company

Position(s) Applied For:
Date of Application
Trade:
Local Union:
Journeyman:
Apprentice:
Referral Source:
- Advertisement
- Employee
- Gov't Employment Agency
- Walk-in
- Private Employment Agency
- Other
Other:
Name of Source (If Applicable)
Name
Last First Middle
Address
Street Address City State Zip Code
Home Telephone #
Last 4 Digits of SSN
Cell Phone #
Date of Birth:
Email
Employment History
List your last two (2) employers, assignment or volunteer activities, starting with the most recent, including military experience. Explain any gaps in employment in comment section below.
Employers
Telephone:
Dates Employed
To From
Address
Job Title
Hourly Rate/Salary [ Starting ]
$ Per
Immediate Supervisor and Title
Reason for Leaving
Hourly Rate/Salary [ Final ]
$ Per
May we contact for references?
- No
- Later
Summarize the nature of the work performed and job responsibilities.
Employers
Telephone:
Dates Employed
To From
Address
Job Title
Hourly Rate/Salary [ Starting ]
$ Per
Immediate Supervisor and Title
Reason for Leaving
Hourly Rate/Salary [ Final ]
$ Per
May we contact for references?
- No
- Later
Summarize the nature of the work performed and job responsibilities.
Skills and Qualifications: Summarize specials skills and qualifications acquired from employment or other experience that may qualify you to work with our company.

EDUCATIONAL BACKGROUND (if job related)
A. List three (3) schools attended, starting with last one. B. List number of years completed. C. Indicate degree or diploma earned, if any. D Grade Point Average or Class Rank and E. Major and minor field of study (if applicable).
A. School B. No. Years Completed C. Degree/Diploma D. GPA/ Class Rank Major Minor
List name and telephone numbers 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 Telephone Years Known
List professional trade, business, or civic associations and any offices held. (Exclude memberships which would reveal sex, race, religion, national origin, age, color, disability or other protected status.
Organization Offices Held
It is understood and agreed upon that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separation from the employer's service if I have been employed.

I give the employer the right to investigate all references and to secure additional information about me, if job related. I hereby release from liability the Employer and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.

The Employer is an Equal Opportunity Employer. The Employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant's consideration for employment on a basis prohibited by local, state, or federal law.

This application is current for only 60 days. At the conclusion of this time, if I have not heard form the Employer and still wish to be considered for employment, it will be necessary to fill out a new application.

I understand that just as I am free to resign at any time, the Employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the Employer has the authority to make any assurances to the contrary.
Signature
Date
Aetna Bridge Company is an Equal Opportunity Employer and adheres to Executive Order 11246; Section 503 of the Rehabilitation ACT of 1973; the Vietnam Era Veterans’ Assistant Ace of 1974; and the American with Disabilities Act of 1990, and their amendments.

INVITATION TO SELF IDENTITY
Solely for Affirmative Action Purposes
This information is voluntarily given and your decision to not answer these questions will not affect our decision to hire you.
1. Do you have any physical or mental limitations which might preclude you from performing any duties on the job?
- Yes
- No
If yes, please explain how we might assist and accommodate your disability.
2. Are you a veteran
- Yes
- No
Date of Service:
During Vietnam Era?
Disabled Veteran?
- Yes
- No
Disabled Non-Veteran?
- Yes
- No
Aetna Bridge Company is an Equal Opportunity Employer and adheres to Executive Order 11246; Section 503 of the Rehabilitation ACT of 1973; the Vietnam Era Veterans’ Assistant Ace of 1974; and the American with Disabilities Act of 1990, and their amendments.
CAPTCHA

Step 1 of 4

Employment History

EDUCATIONAL BACKGROUND (if job related)

VOLUNTARY AFFIRMATIVE ACTION INFORMATION

INVITATION TO SELF IDENTITY

Aetna Bridge Company is an Affirmative Action/Equal Opportunity Employer.