DMK Associates: Application for Employment

Instructions: It is the policy of DMK Associates to provide equal opportunity with regard to all terms and conditions of employment. DMK Associates complies with federal and state laws prohibiting discrimination on the basis of race, color, religion, sex, national origin, disability, veteran status, age, or any other protected characteristic.

FIRST NAME

MIDDLE NAME

LAST NAME

PHONE

ADDRESS: STREET

ADDRESS: CITY

ADDRESS: STATE

ZIP CODE

Social Security #

Position applied for

SHIFT PREFERRED:

Shift preferred 1 2 3 Any

Expected pay

Would you accept full-time work?

Yes No

Would you accept part-time work?

Yes No

On what date would you be available for work?

Date

Have you ever been employed here?

Yes No

If yes, please give dates

If you are under 18 years old, can you provide a work permit if required?

Yes No

Are you legally eligible for employment in the United States? If yes, proof is required if hired.

Yes No

Are you able to perform the essential functions of the job for which you are applying (with or without reasonable accommodation)? This question is not designed to elicit information about an applicant’s disability. Please do not provide information about the existence of a disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stage, to the extent permitted by law.

Yes No Need more information about the job's essential functions to respond.

Have you entered into an agreement with any former employer or other party (such as a non competition agreement) that might, in any way, restrict your ability to work for our company?

Yes No

If yes, please explain:

Explain any gaps in your employment, other than those due to personal illness, injury or disability.

Have you ever been fired or asked to resign from a job?

Yes No

If yes, please explain.

Languages, machine operation, etc., that would be of benefit in the job for which you are applying.

Employer 1: Check the box if you DO NOT want us to contact this employer.

Do NOT contact

Employer Name:

Contact Name:

Address:

Phone:

Job Title:

Supervisor:

Dates employed: From (mm/yy)

Dates employed: To (mm/yy)

Hourly rate/salary: (starting)

Hourly rate/salary: (final)

Work Performed:

Reason for leaving:

Employer 2: Check the box if you DO NOT want us to contact this employer.

Do NOT contact

Employer Name:

Contact Name:

Address:

Phone:

Job Title:

Supervisor:

Dates employed: From (mm/yy)

Dates employed: To (mm/yy)

Hourly rate/salary: (starting)

Hourly rate/salary: (final)

Work Performed:

Reason for leaving:

Employer 3: Check the box if you DO NOT want us to contact this employer.

Do NOT contact

Employer Name:

Contact Name:

Address:

Phone:

Job Title:

Supervisor:

Dates employed: From (mm/yy)

Dates employed: To (mm/yy)

Hourly rate/salary: (starting)

Hourly rate/salary: (final)

Work Performed:

Reason for leaving:

Employer 4: Check the box if you DO NOT want us to contact this employer.

Do NOT contact

Employer Name:

Contact Name:

Address:

Phone:

Job Title:

Supervisor:

Dates employed: From (mm/yy)

Dates employed: To (mm/yy)

Hourly rate/salary: (starting)

Hourly rate/salary: (final)

Work Performed:

Reason for leaving:

High School and Location:

Did you graduate?

Yes No

College and Location:

Course of Study?

Did you graduate?

Yes No

Degree or Diploma

Graduate School/Location:

Course of study

Did you graduate?

Yes No

Degree or Diploma

Vocational Training (or other) and Location:

Course of study

Did you graduate?

Yes No

Degree or diploma

Continuing Education

Please include copies of your certifications if any are applicable.

This Company does not tolerate unlawful discrimination or harassment based on sex, race, color, religion, national origin, citizenship, age, disability, or any other protected status under applicable federal, state or local laws. No question on this application is used to limit or exclude an applicant from employment consideration. Harassment of our employees is strictly prohibited, whether it is committed by a manager, coworker, subordinate, or non-employee (such as a vendor or customer Examples of prohibited harassment include, but are not limited to, unwelcome physical contact, comments, jokes, or epithets, threats, insults, name-calling, offensive gestures, negative stereo- typing, possession or display of derogatory pictures or other graphic materials, and any other words or conduct that demean, stigmatize, intimidate, or single out a person because of his/her membership in a protected category. The Company takes all complaints of harassment seriously and each will be investigated promptly and thoroughly.

I certify that all the information submitted by me on this application is true and complete, and I understand that if any false or misleading information, omissions or misrepresentations are discovered, my application may be rejected, and if I am employed, my employment may be terminated at any time. If hired, I agree to conform to the Company’s rules and regulations, and I understand that these rules and/or the employee handbook do not form a contract of employment either expressed or implied, and I agree that my employment and compensation can be terminated, with or without cause and with or without notice, at any time, at either my or the Company’s option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause and with or without notice, at any time by the Company. I understand that no Company representative, other than its president, and then only when in writing and signed by the president, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the forgoing. I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, résumé or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives for seeking, gathering and using truthful and nondefamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me. I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.

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