BILL ANSKIS COMPANY, INC.
465 Industrial Park Rd, Elyburg, PA 17824; Tele: 570-644-0146/Fax: 570-644-3906
Employment Application
COMPANY EEO POLICY STATEMENT
It is the policy of this company to assure that applicants are employed, and that employees are treated during employment without regard to their race, religion, sex, color, national origin, age, or disability. Such action shall include: Employment, upgrading, demoting, or transfer; recruitment advertising; layoff or termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship, pre-apprenticeship, and/or on the job training.
Applicant Information
Full Name
Address
City, State, Zip Code
Phone
E-Mail Address
Date of Birth
Driver's License No.
Date Available
Desired Salary
Position Applied for
Are you a citizen of the United States?
Yes
No
If no, are you authorized to work in the U.S.?
Yes
No
Have you ever worked for this company?
Yes
No
If yes, when?
Have you ever been convicted of a felony?
Yes
No
If yes, explain:
Do you have a valid Driver's License?
Yes
No
If no, explain:
Education
1) High School
Address
Dates attended
Did you graduate?
Yes
No
Degree
2) College
Address
Dates attended
Did you graduate?
Yes
No
Degree
3) Other Education
References
Please list three professional references
1) Full Name
Company
Address
Relationship
Phone
2) Full Name
Company
Address
Relationship
Phone
3) Full Name
Company
Address
Relationship
Phone
Previous Employment
1) Company
Address
Phone
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
Dates Employed
Reason for Leaving
May we contact your previous supervisor for a reference?
Yes
No
2) Company
Address
Phone
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
Dates Employed
Reason for Leaving
May we contact your previous supervisor for a reference?
Yes
No
3) Company
Address
Phone
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
Dates Employed
Reason for Leaving
May we contact your previous supervisor for a reference?
Yes
No
Military Service
Branch
Dates served
Rank at Discharge
Type of Discharge
If other than honorable, explain:
Additional Comments
Please enter any other information:
Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Signature
Date
VOLUNTARY SELF IDENTIFICATION FORM
Bill Anskis Company, Inc. is an equal Opportunity Employer. As required by law, we must record certain information to be made part of our Affirmative Action Program. Applicants for employment are also invited to participate in the Affirmative Action Program by reporting their status as handicapped, disabled veteran, veteran of the Vietnam era or other minority. In extending this invitation you are also advised that: (a) workers (applicants) are under no obligation to respond, but may do so in the future if they choose; (b) responses will remain confidential within the Human Resources Department; and (c) responses will be used only for the necessary information to include in our Affirmative Action Program. We are a company that values diversity. We actively encourage women and minorities to apply. Refusal to provide this information will have no bearing on your application and will not subject you to any adverse treatment.
Please Complete the following information requested below. Thank you for your cooperation.
Applicant Information
Full Name
Date
Position Applied For
Self Identification
Please Check All That Apply (see below for definitions)
Race or Ethnic Identity
Hispanic or Latino
White (not Hispanic or Latino)
Black or African American (not Hispanic or Latino)
Native Hawaiian or Pacific Islander (not Hispanic or Latino)
Asian (not Hispanic or Latino)
American Indian or Alaskan Native (not Hispanic or Latino)
Two or More Races (not Hispanic or Latino)
Gender
Male
Female
Veteran Status
Vietnam Era Veteran
Other Eligible Veteran
I do not wish to self-identify.
Signature
How did you find out about our opening?
Company Employee
Newspaper Ad
Recruiter
Career Fair
Company Website
State Employment Website
EE0 RACE/ETHNIC IDENTIFICATION CATEGORIES AND DEFINITIONS
Hispanic or Latino
A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
White (Not Hispanic or Latino)
A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Black or African American (Not Hispanic or Latino)
A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)
A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Asian (Not Hispanic or Latino
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 (Not Hispanic or Latino)
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 who identify with more than one of the above five races.
Veteran of the Vietnam Era
Defined as a veteran who (a) served on active duty in the Republic of Vietnam between February 28, 1961 and May 7, 1975, or (b) served on active duty for a period of more than 180 days, any part of which occurred between August 5, 1964 and May 7, 1975, and was discharged or released there from with other than dishonorable discharge, or (c) was discharged or released from active duty for a service-connected disability if any parts of his or her active duty was performed between August 5, 1964 and May 7, 1975.
Other Eligible Veteran
Defined as any veteran who served in a “war” declared by Congress, in a campaign or on an expedition for which a campaign badge, service medal, or an expeditionary medal has been awarded.
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