Application for Employment
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Application for Employment
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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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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.
VOLUNTARY AFFIRMATIVE ACTION INFORMATION
We consider applicants for all positions without regard to race, color religion, sex, national origin, disability, veteran status of any other legally protected status.
Referral Source:
Advertisement
Employee
Gov't Employment Agency
Walk-in
Private Employment Agency
School
Relative
Other
As required, we comply with government regulations including Affirmative Action obligations where they apply.
In an effort to comply with requirements regarding government recordkeeping, reporting and other legal obligations, we ask that you complete this applicant data survey. Your cooperation is appreciated.
Please be advised that your survery is
not
a part of your official application for employment. It is considered confidential information that will not be used in any hiring decision.
Check one:
Male
Female
Check one of the following Race/Ethnic Group:
Hispanic
Black
White
American Indian/Alaskan Native
Asian/Pacific Islander
SPECIAL NOTICE TO VIETNAM ERA VETERANS, DISABLED VETERANS AND INDIVIDUALS WITH PHYSICAL OR MENTAL HANDICAPS OF DISABILITIES.
Government contractors subject to the Vietnam Era Veterans Readjustment Act of 1974 and the Rehabilitation Act of 1973 are required to take affirmative action to employ and advance in employment qualified disabled veterans and veterans of the Vietnam Era, and qualified handicapped individuals.
You are invited to volunteer this information, if you qualify, to assist in proper placement and determining reasonable accommodation. This information will be considered confidential, and refusal to provide this information will not adversely affect your consideration for employment.
IF YOU SO WISH TO BE IDENTIFIED, PLEASE CHECK IF ANY OF THE FOLLOWING ARE APPLICABLE:
VIETNAM ERA VETERAN
DISABLED VETERAN
INDIVIDUAL WITH A DISABILITY
To be completed by applicant- Not for interview purposes - To be filed separately from application.
This information is used to satisfy the Affirmative Action requirements of Section 503 of the Rehabilitation Act or necessitated by another federal law or regulation.
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.
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