Employment Application Form

ADDITIONAL INFORMATION
Employers must make reasonable accommodations for qualified individuals with disabilities in the application process and during employment. Under Michigan law only, a disabled individual needing an accommodation must submit a written request within 182 days of the date the individual knows of the need for accommodation. There is no similar requirement under the Americans with Disabilities Act, although failure to notify the Company of the need for accommodation may preclude a claim that the Company failed to provide reasonable accommodation.
Are you capable of performing the essential functions of the position for which you are applying, with or without a reasonable accommodation?*

YesNo
Do you have a valid driver’s license?*

YesNo
License No.
State
List professional trade, business or civic activities and offices held, excluding groups whose name or character indicaterace, color, religion, sex, national origin, gender identity, sexual orientation, disability, marital or veteran status.*
List a name, address, and telephone number of a person to be notified in the event of accident or emergency.*
EMPLOYMENT EXPERIENCE
Can we contact your current employer?*

YesNo
Please list all previous employers (most recent first).
Employer*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Job Title*
Supervisor*
Work Performed*
Reason for Leaving*
Date Started*

MonthDayYear
Date
Date Left*

MonthDayYear
Date
Starting Wage/Salary*
Final Wage/Salary
Employer*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Job Title*
Supervisor*
Work Performed*
Reason for Leaving*
Date Started*

MonthDayYear
Date
Date Left

MonthDayYear
Date
Starting Wage/Salary
Final Wage/Salary*

Employer*
Phone Number

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Job Title*
Supervisor*
Work Performed
Reason for Leaving*
Date Started*

MonthDayYear
Date
Date Left

MonthDayYear
Date
Starting Wage/Salary
Final Wage/Salary
Employer*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Job Title*
Supervisor*
Work Performed*
Reason for Leaving*
Date Started

MonthDayYear
Date
Date Left*

MonthDayYear
Date
Starting Wage/Salary*
Final Wage/Salary*
EDUCATION
High School
Location of School
Course of Study
# YearsCompleted (select one)
Diploma / Degree
Undergraduate College
Location of School
Course of Study
# YearsCompleted (select one)
Diploma / Degree
Graduate College
Location of School
Course of Study
# YearsCompleted (select one)
Diploma / Degree
OtherEducation (Specify)
Location of School
Course of Study
# YearsCompleted (select one)
Diploma / Degree
REFERENCES
List three persons familiar with your character, ability or education for more than one year. Please do not include relatives.
Reference 1*
Name of Reference
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Email*
Reference 2*
Name of Reference
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Email*
Reference 3*
Name of Reference
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Email*
AUTHORIZATION AND UNDERSTANDING
I certify that all information given in this Application is true and complete. I authorize the Company to investigate my work and personal history and verify all data given on this Application and in interviews. This inquiry may include information as to my character, general reputation and personal characteristics, and I consent to the conduct of this inquiry and to the consideration of any statements or references by former employers that are given in response to the inquiry. I authorize all individuals, schools and employers named, except as specifically limited on this application, to provide information requested about me, and I release them and the Company from liability for damages in providing or using this information. I understand and acknowledge that any misrepresentation, omission, or incorrect statement of fact can result in rejection of my application or, if hired, immediate discharge.

I also understand that if hired, my employment will be at the will of the Company and can be terminated with or without cause, and with or without notice, at any time at the option of either the Company or me. I further understand that no manager, representative, agent or employee of the Company, other than its President, has now or has had in the past any authority to enter into any agreement for employment for any specified period of time or to make any agreement which is contrary to or a modification of the at-will employment relationship. Any modification of the at-will employment relationship must be by the President of the Company in a writing that specifically acknowledges that it is a modification of the at-will employment relationship and that is signed by the President of the Company. I am aware that any collective bargaining agreement covering my employment may also alter the at-will nature of my employment.

I understand that as a part of the hiring process I may be required to submit to an alcohol and/or drug test, and that throughout my employment, if hired, I may be required to submit to medical/physical examinations (which may include but are not limited to tests for drugs and/or alcohol) at the Company’s discretion and expense. I authorize all testing laboratories to release test results to the Company, and I agree the Company has the right to use such results in decisions affecting my employment, and I authorize the Company to use the results for such purposes. I understand that if I am made an offer of employment, I may be required to complete a pre-employment physical and alcohol and drug screen or the offer of employment may be revoked. I am aware that any collective bargaining agreement covering my employment may alter this policy.

I acknowledge that during the application process, the Company may inquire as to any criminal convictions I have had. Conviction of a crime is not necessarily a bar to employment. The Company will consider all facts and circumstances surrounding that conviction, including age of the conviction and nature of the offense, before determining if the conviction will affect the status of my application.

I understand and agree that if I become employed by the Company, in consideration for my employment I will not commence any action, including any administrative claim or lawsuit, against the Company, its agents or employees, which in any way relates to my employment and/or termination of my employment, more than six (6) months after the date of the event giving rise to said actions. I acknowledge that the statute of limitations for some claims may be longer and I HEREBY KNOWINGLY AND VOLUNTARILY WAIVE ANY STATUTE OF LIMITATIONS TO THE CONTARY.
Date*

MonthDayYear
Date
Applicant’s Signature*

Clear

E.C. Korneffel

Criminal Records Check Policy
This Company obtains criminal conviction record checks on applicants for employment whom the Company choses to interview or otherwise determines are qualified. The Company only reviews criminal convictions. It does not review arrest records. Criminal records are reviewed on a caseby- case basis to determine if they are a bar to employment.

Generally speaking, the Company considers the following as a possible bar to employment:

1. Convictions for crimes involving dishonesty, drug possession or sales, or violence

2. Convictions for driving offenses involving alcohol or drug use, if the applicant is applying for a job requiring driving

3. Any criminal convictions within seven (7) years of the application date that the Company deems in its discretion would disqualify the applicant from further consideration for employment

An applicant who falsifies information provided to the Company during the application process by indicating they do not have a criminal conviction when, in fact, they do, will not be hired; or, if the applicant has already been hired, they will be terminated from employment.

An employee who is charged with a felony during their employment must notify the Company in writing within five (5) days of the charge. Failure to timely notify the Company may result in termination of employment. The Company may terminate an employee’s employment if proceedings involving the pending felony charge will interfere with the employee’s ability to perform their job, including their ability to adhere to the Company’s attendance standards.

An employee who is convicted of a crime during employment must notify the Company in writing within five (5) days of the conviction. Failure to timely notify the Company may result in termination of employment. The Company will assess on a case-by-case basis whether the criminal conviction disqualifies the employee from further employment.

Appropriate steps will be taken to maintain the confidentiality of information received regarding an applicant’s or employee’s criminal records. Records will be maintained apart from an employee’s or applicant’s general file and access to those records will be limited to those employees of the Company with a need to know the information or who are responsible for keeping the records.

Criminal Conviction Disclosure Form
As an applicant whom the Company has decided to interview or otherwise considered to be qualified for employment, you are being asked to disclose the following information:
Have you ever been convicted of a crime?

YesNo
If you answered “yes” to the above question, please provide the following information:
1. What was the nature of the offense for which you were convicted?
2. What was the date of the conviction, as close as you can recall?
3. In what court were you convicted, or if you cannot recall the name of the court, in whatCity and State were you convicted?
4. What was the criminal case number associated with the conviction?
A criminal conviction will not be an automatic bar to employment. Circumstances such as the age and nature of the offense will be considered when determining whether the conviction acts as a bar to employment.

E.C. Korneffel Co.Voluntary Self-Identification

Confidential: For Statistical Use Only
E.C. Korneffel Co. is subject to Executive Order 11246, which requires government contractors andsubcontractors to take affirmative action to employ and advance in employment, women and minorities and to keep records relating to the hiring of women and minorities. For that reason, we ask that you provide the information requested below.

Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information provided will be used only in ways that are not inconsistent with Executive Order 11246. The information you submit will be kept confidential, except that Government officials engaged in enforcing laws administered by OFCCP may be informed.

We are an equal opportunity employer and will not unlawfully discriminate against an employee or applicant on the basis of race, sex, color, religion, marital status, public benefit status, genetic information, age, veteran status, the presence of a disability, national origin, sexual orientation, gender identity or any other protected characteristic.
Please complete the information requested below. Thank you for your cooperation.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Position Applied for:*
Gender

MaleFemale
Race or Ethnic Identity:*

Hispanic or Latino: A person of Mexican, Puerto Rican, Cuban, Central or SouthAmerican, or other Spanish culture or origin, regardless of raceWhite: A person having origins in any of the original peoples of Europe, NorthAfrica, or the Middle EastBlack or African-American: A person having origins in any of the black racial groups of Africa.Native Hawaiian orOther Pacific Islander: A person having origins in any of the original peoples of Hawaii,Guam, Samoa, or other Pacific IslandsAsian: Southeast Asia, or the Indian subcontinent, including, for example,Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, thePhilippine Islands, Thailand, and VietnamAmerican Indian orAlaskan Native: A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribalaffiliation or community attachmentTwo of More Races: All persons who identify with more than one of the above five races
Should be Empty:

Application for Employment

PERSONAL INFORMATION

EMPLOYMENT DESIRED

MILITARY SERVICE DATA

ADDITIONAL INFORMATION

EMPLOYMENT EXPERIENCE

EDUCATION

REFERENCES

AUTHORIZATION AND UNDERSTANDING

E.C. Korneffel

Criminal Conviction Disclosure Form

E.C. Korneffel Co.Voluntary Self-Identification