PERSONAL INFORMATION (required)

Last Name:

First Name:

Middle Initial:

Today's Date:

Address:

City:

State:

Zip Code:

Home Phone#:

Cell Phone:

Your Email:

 

EMPLOYMENT INQUIRIES (required)

Position Applying For:

click here for open positions

Available Start Date:

Salary Expected:

Per HourPer Year

Would you accept full time work?
YesNo

Would you accept part time work?
YesNo

Were you previously employed by us?
YesNo

If yes, when?:

Are you currently employed?
YesNo

Are you over 18?
YesNo

If no, can you provide proof of eligibility to work?:
YesNo

Have you ever been convicted of a felony?
YesNo

If yes, explain:

Are you legally eligible to work in the U.S.?
YesNo

If you are applying for a position that requires driving, do you possess a valid driver's license?
YesNoN/A

Will you now or in the future require sponsorship for employment visa status, (e.g., H-1B status)?
YesNo

If yes, explain:

Have you ever served in the U.S Armed Forces?
YesNo

If Yes, Dates of Duty:

Branch:

Applicable skills acquired:

 

EMPLOYMENT HISTORY

Start with your present or last job. Include any job related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disability or other protected status.

Employer Name:

Dates Employed:
From:

To:

Hourly Rate/Salary:
Beginning:

Ending:

Employer Address:

Supervisor's Name:

Supervisor's Title:

Telephone:

Reason for Leaving:

Position (Job Title):

Full time:
YesNo

Part Time:
YesNo

Work Performed:

May we contact this employer?
YesNo

 

Employer Name:

Dates Employed:
From:

To:

Hourly Rate/Salary:
Beginning:

Ending:

Employer Address:

Supervisor's Name:

Supervisor's Title:

Telephone:

Reason for Leaving:

Position (Job Title):

Full time:
YesNo

Part Time:
YesNo

Work Performed:

May we contact this employer?
YesNo

 

Employer Name:

Dates Employed:
From:

To:

Hourly Rate/Salary:
Beginning:

Ending:

Employer Address:

Supervisor's Name:

Supervisor's Title:

Telephone:

Reason for Leaving:

Position (Job Title):

Full time:
YesNo

Part Time:
YesNo

Work Performed:

May we contact this employer?
YesNo

 

EDUCATION BACKGROUND

High School:
1234

College/University:
1234

Graduate School:
1234

Vocational Training:
1234

Other:
1234

Other Qualifications:
Please list any special training or skills you have acquired. Include special machines or equipment you can operate, languages you can speak/read/write, and any other knowledge that has provided you with qualifying skills for the position.

 

REFERENCES (required)

Please provide information for three individuals, other than relatives or friends, whom we may contact for a professional recommendation.

Name:

Address:

Telephone:

Occupation:

Relationship to you:

Years Known:

 

Name:

Address:

Telephone:

Occupation:

Relationship to you:

Years Known:

 

Name:

Address:

Telephone:

Occupation:

Relationship to you:

Years Known:

 

CRIMINAL RECORD (required)

Have you ever been convicted of a misdemeanor or felony? YesNo

If yes, please list all convictions including dates, charge and explanation:

 

EMPLOYMENT INQUIRY RELEASE (required)

In conjunction with my continued employment (including contract services) with you, I understand that you may hire Selection.com to obtain "Consumer Reports" about me as defined in the Fair Credit Reporting Act (FCRA). These "Consumer Reports" may include information concerning my credit worthiness, credit standing, credit capacity, character, academic background, credentials, work habits, work performance, work experience, reasons for work termination, general reputation, personal characteristics or mode of living. You also may seek information concerning my employment history, workers' compensation history, motor vehicle record, education background, civil litigation history and/or criminal record.

I understand that you may rely on any or all of the above referenced information in determining my continued eligibility for employment. If you contemplate making an adverse employment-related decision that will affect me based, in whole or in part, upon a "Consumer Report" obtained from Selection.com, I will be provided with a copy of the "Consumer Report" and a written summary of my "Consumer Rights" under the FCRA before you finalize that decision.

I have read the above disclosure and I hereby authorize you, Selection.com or its authorized agents to obtain the above referenced information about me. I also authorize all agencies, bureaus, employers, information service organizations and individuals to provide any of the above referenced knowledge or information they have concerning me. Furthermore, this authorization shall remain on file and shall serve as an ongoing authorization for you to obtain "Consumer Reports" about me from SMS at any time during my employment with you. A photocopy or facsimile of this authorization shall be as valid as the original.

Signature (Type Name):

Date:

THE FOLLOWING INFORMATION IS REQUIRED TO CONDUCT THE BACKGROUND INVESTIGATION

Last Name

First Name

Middle Initial

Social Security Number

PREVIOUS OR MAIDEN NAME (if applicable)

PHONE NUMBER

STREET ADDRESS

CITY

STATE

ZIP

DRIVER'S LICENSE NUMBER

STATE ISSUED

List states and counties of residence, other than above, for the past seven (7) years:

COUNTY

STATE

COUNTY

STATE

COUNTY

STATE

FOR IDENTIFICATION PURPOSES ONLY:

Date of birth

My prospective employer understands age to be a protected characteristic and the information requested will not be used as the basis for any employment decision.

Notice to Applicants Living in CA, OK or MN
By checking this box, I request to receive a free copy of any Report ordered on me: Yes

Email address

** By entering my email address, I authorize Selection.com to deliver my Report via email

Notice to California Residents: Under section 1786.22 of the California Civil Code, you may view the file maintained on you by Selection.com during normal business hours. You may also obtain a copy of this file, either in person or by mail, by submitting proper identification and paying the costs of duplication services. You may also receive a summary of the file by telephone by being able to provide adequate identification as to allow Selection.com to determine with reasonable certainty that you are the subject of the report. Selection.com is required to have personnel available to explain your file to you and must explain to you any coded information appearing in your file. If you appear in person, another person of your choice may accompany you, providing that this additional person furnishes proper identification.

 

FAIR CREDIT REPORTING ACT DISCLOSURE

In conjunction with my application for employment (including contract services) with you, my prospective employer, I understand that you intend to hire Selection.com to obtain Consumer Reports and / or Investigative Consumer Reports (hereinafter called "Reports") about me as defined in the Fair Credit Reporting Act (FCRA). These "Reports" may include information concerning my credit worthiness, credit standing, credit capacity, character, academic background, credentials, work habits, work performance, work experience, reasons for work termination, general reputation, personal characteristics or mode of living. You also may seek information concerning my employment history, workers' compensation history, motor vehicle record, education background, civil litigation history and/or criminal record.

I understand that you may rely on any or all of the above referenced information in determining whether to extend an offer of employment to me. If you contemplate making an adverse employment-related decision that will affect me based, in whole or in part, upon a "Report" obtained from Selection.com, I will be provided with a copy of the 'Report" and a written summary of my Consumer Rights under the FCRA before you finalize that decision.

I have read the above disclosure and I hereby authorize you, Selection.com or its authorized agents to obtain the above referenced information about me. I also authorize all agencies, bureaus, employers, information service organizations and individuals to provide any of the above referenced knowledge or information they have concerning me. If I am hired, this authorization shall remain on file and shall serve as an ongoing authorization for you to obtain "Reports" about me from Selection.com at any time during my employment with you. A photocopy or facsimile of this authorization shall be as valid as the original. I agree that any and all disputes arising from this "Report" shall be brought only in state or federal court in the State of Ohio and shall be governed by, and construed in accordance with, the laws of the State of Ohio.

Signature (type full name)

Date

Notice to Applicants living in CA, OK or MN:

By checking this box, I request to receive a free copy of any consumer report ordered on me: Yes

Email address

**By entering my email address, I authorize Selection.com to deliver my report via email.

Notice to California Residents: Under section 17B6.22 of the California Civil Code, you may view the file maintained on you by Selection.com during normal business hours. You may also obtain a copy of this file, either in person or by mail, by submitting proper identification and paying the costs of duplication services. You may also receive a summary of the file by telephone by being able to provide adequate identification as to allow Selection.com to determine with reasonable certainty that you are the subject of the report. Selection.com is required to have personnel available to explain your file to you and must explain to you any coded information appearing in your file. If you appear in person, another person of your choice may accompany you, providing that this additional person furnishes proper identification. Selectiorecom's Privacy Policy can be viewed at www.Selection.com.

THIS FORM IS FOR PERMANENT RETENTION IN PERSONNEL FILE.

 

Job Applicant's Agreement and Certification (required)

I certify that the information given by me in this application is true in all respects and agree that if the information is found to be false in any way, it shall be considered sufficient cause for denial of employment or discharge. I authorize the use of any information in this application to verify my statements.

I authorize past employers, references, and any other persons to answer all questions asked concerning my eligibility, character, reputation, and previous employment record. I release all such persons from any liability for have furnished such information.

I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract. No promise regarding employment has been made to me, and I understand that no such promise or guarantee is binding upon you.

I understand that if employed, policies and rules that are issues are not conditions of employment and that the Freestore Foodbank may revise policies or procedures, in whole or in part, at any time. The Freestore Foodbank reserves and retains the right to make changes in terms and conditions of my employment as the Freestore Foodbank determines to be appropriate.

I understand that this application will be kept on file for one year from the date completed, after which time I would have to reapply in accordance with established company procedures.

I understand that if employed with the Freestore Foodbank, Inc. it is "at will" which means that my employment can be terminated with or without cause, with or without notice, and at any time at the option of either the Freestore Foodbank Inc. or myself, except as otherwise provided by law.

Applicant's E-Signature:

Date: