Application for Employment

Application for Employment
PLEASE PRINT
Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department.
Position(s) applied for *
Date of application *

Month Day Year
Date
First Name *
Middle Name
Last Name *
Address
Street *
City *
State
ZIP Code
Telephone
Please enter a valid phone number.
Mobile / Beeper / Other Phone *
Please enter a valid phone number.
Email *
example@example.com
Social Security #
If you are under I8, and it is required, can you furnish a work permit? *

Yes No
If no, please explain
Have you ever been employed here before?

Yes No
Are you legally eligible for employment in this country?

Yes No
Date available for work

Month Day Year
Date
Type of employment desired

Full-Time Part-Time Seasonal Temporary Educational Co-Op
Are you able to meet the attendance requirements of the position?

Yes No
Have you been convicted of a crime in the last seven (7) years?

Yes No
If yes, please explain
CONVICTION WILL NOI NECESSARILY BE A BAR TO EMPLOYMENT. EACH INSTANCE AND EXPLANATION WILL BE CONSIDERED IN RELATION TO THE POSITION FOR WHICH YOU ARE APPLYING
Driver's license number if driving is an essential job function
State
Employment History

Provide the following information for your past four (4) employers, assignments or volunteer activities, starting with the most recent.
FROM
TO
EMPLOYER
TELEPHONE
JOB TITLE
ADDRESS
IMMEDIATE SUPERVISOR AND TITLE
SUMMARIZE THE NATURE OF WORK PERFORMED AND JOB RESPONSIBILITIES
REASON FOR LEAVING
START
HOURLY RATE / SALARY
PER
HOURLY RATE / SALARY
FINAL
HOURLY RATE / SALARY
PER
HOURLY RATE / SALARY
FROM
REASON FOR LEAVING
TO
REASON FOR LEAVING
EMPLOYER
TELEPHONE
JOB TITLE
ADDRESS
IMMEDIATE SUPERVISOR AND TITLE
SUMMARIZE THE NATURE OF WORK PERFORMED AND JOB RESPONSIBIUTIES
REASON FOR LEAVING
START
HOURLY RATE / SALARY
PER
HOURLY RATE / SALARY
FINAL
HOURLY RATE / SALARY
PER
HOURLY RATE / SALARY
FROM
TO
EMPLOYER
TELEPHONE
JOB TITLE
ADDRESS
IMMEDIATE SUPERVISOR AND TITLE
SUMMARIZE THE NATURE OF WORK PERFORMED AND JOB RESPONSIBILITIES
REASON FOR LEAVING
START
HOURLY RATE / SALARY
PER
HOURLY RATE / SALARY
FINAL
HOURLY RATE / SALARY
PER
HOURLY RATE / SALARY
FROM
TO
EMPLOYER
TELEPHONE
JOB TITLE
ADDRESS
IMMEDIATE SUPERVISOR AND TITLE
SUMMARIZE THE NATURE OF WORK PERFORMED AND JOB RESPONSIBILITIES
REASON FOR LEAVING
START
HOURLY RATE / SALARY
PER
HOURLY RATE / SALARY
FINAL
HOURLY RATE / SALARY
PER
HOURLY RATE / SALARY
AN EQUAL OPPORTUNITY EMPLOYER
Skills and Qualifications
Summarize any training, skills. licenses, and/or certificates that may qualify you as being able to perform job related functions in the position for which you are applying.
Educational Background

IF JOB-RELATED
HIGH SCHOOL
YEARS COMPLETED
DID YOU GRADUATE?
COURSE OF STUDY
COLLEGE
YEARS COMPLETED
DID YOU GRADUATE?

MAJOR DEGREE
COURSE OF STUDY
OTHER
YEARS COMPLETED
DID YOU GRADUATE?
COURSE OF STUDY
References
NAME
TELEPHONE
Please enter a valid phone number.
YEARS KNOWN
NAME
TELEPHONE
Please enter a valid phone number.
YEARS KNOWN
NAME
TELEPHONE
Please enter a valid phone number.
YEARS KNOWN
I UNDERSTAND THAT IF IAM EMPLOYED. ANY MISREPRESENTATION OR MATERIAL OMISSION MADE BY ME ON THIS APPLICATION WILL BE SUFFICIENT CAUSE FOR CANCELLATION OF THIS APPLICATION OR IMMEDIATE DISCHARGE FROM THE EMPLOYER'S SERVICE. WHENEVER IT IS DISCOVERED.

I GIVE THE EMPLOYER THE RIGHT TO CONTACT AND OBTAIN INFORMATION FROM ALL REFERENCES. EMPLOYERS. EDUCATIONAL INSTITUTIONS AND TO OTHERWISE VERIFY THE ACCURACY OF THE INFORMATION CONTAINED IN THIS APPLICATION, I HEREBY RELEASE FROM LIABILITY THE EMPLOYER AND ITS REPRESENTATIVES FOR SEEKING. GATHERING AND USING SUCH INFORMATION AND ALL OTHER PERSONS, CORPORATIONS OR ORGANIZATIONS FOR FURNISHING SUCH INFORMATION.

THE EMPLOYER DOES NOT UNLAWFULLY DISCRIMINATE IN EMPLOYMENT AND NO QUESTION ON THIS APPLICATION IS USED FOR THE PURPOSE OF LIMITING OR EXCUSING ANY APPLICANT FROM 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 HAVE NOT HEARD FROM THE EMPLOYER AND STILL WISH TO BE CONSIDERED FOR EMPLOYMENT. IT WILL BE NECESSARY TO FILL OUT A NEW APPLICATION

IF I AM HIRED,UNDERSTAND THAT I AM FREE TO RESIGN AT ANY TIME, WITH OR WITHOUT CAUSE AND WITHOUT PRIOR NOTICE, AND THE EMPLOYER RESERVES THE SAME RIGHT TO TERMINATE MY EMPLOYMENT AT ANY TIME, WITH OR WITHOUT CAUSE-AND WITHOUT PRIOR NOTICE, EXCEPT AS MAY BE REQUIRED BY LAW. THIS APPLICATION DOES NOT CONSTITUTE AN AGREEMENT QR CONTRACT FOR EMPLOYMENT FOR SPECIFIED PERIOO OR DEFINITE DURATION. I UNDERSTAND THAT NO REPRESENTATIVE OF THE EMPLOYER OTHER THAN AN AUTHORIZED OFFICER, HAS THE AUTHORITY TO MAKF. ANY ASSURANCES TO THE CONTRARY. I FURTHER UNDERSTANO THAT ANY SUCH ASSURANCES IUST BE IN WRITING AND SIGNED BY AN AUTHORIZED OFFICER.

I UNDERSTAND IT IS THIS COMPANY'S POLICY NOT TO REFUSE TO HIRE A QUALIFIED INDIVIQUAL WITH A DISABILITY BECAUSE OF THAT PERSON'S NEEO FOR A REASONABLE ACCOMMODATION AS REQUIRED BY THE ADA.

I ALSO UNDERSTAND THAT IF IAM HIRED, I WILL BE REQUIRED TO PROVIDE PROOF OF IDENTITY AND LEGAL WORK AUTHORIZATION.
In Case of Emergency Notify
Name / Relationship
Address
Phone Number
Please enter a valid phone number.
I represent and warrant that I have read and fully understand the foregoing and seck employment under these conditions.
Signature of Applicant

Clear
Date

Month Day Year
Date
You should include this Notice in any application for employment. This Notice should also be posted in an appropriate and conspicuous location on your premises and made available for inspection by the general public during regular business hours in your personnel office. This form should be completed at the time of the employment application.
FlaiR A/C (The Company) has established and maintains a Drug-Free Workplace Program. This Drug-Free Workplace Program is in conformity with chapter 440.102, Florida Statutes, its implementing regulations, and Federal law.
As part of this Program, offers of employment are expressly conditioned upon passing a drug test. In addition, employees of the Company may be subject to drug testing under those conditions outlined in the Company's Drug and Alcohol Policy Statement.

For persons receiving a conditional offer of employment, failure of a drug test or refusal to submit to drug testing when required by the Company shall terminate any job offer. For employees, failing a drug test or refusing to submit to a drug test will result in action against an employee up to and including termination of employment.

Persons receiving a conditional offer of employment will have an opportunity to confidentially report to the Medical Review Officer (MRO) the use of prescription or non-prescription medications both before and after being tested. Additionally, job applicants shall receive a list of common medications which may alter or affect a drug test. Job applicants will also be given the names, addresses, and telephone numbers of local alcohol and drug rehabilitation programs.

Any person receiving a conditional offer of employment who fails a drug test may challenge or explain the result within five working days after written notification of the test result. A job applicant will also have an opportunity to request a retest at the job applicant's expense. If a job applicant's explanation or challenge is unsatisfactory, the job applicant may contest the drug test results pursuant to rules adopted by the Department of Labor and Employment Security or the Agency for Health Care Administration. The job applicant also has the responsibility to notify the laboratory or clinic conducting the drug test of any administrative or civil action brought involving the drug test conducted by that laboratory or clinic. The job applicant also has a right to consult the testing laboratory or clinic for technical information regarding prescription and non-prescription medication. In addition, each job applicant will be given a list of the substances to be tested prior to administration of the drug tests. All test results will remain confidential except as allowed by law. The Company will provide all job applicants with a copy of the Company's Drug and Alcohol Abuse Policy Statement prior to administration of a drug test.

Nothing in this Notice will affect these rights provided in any collective bargaining agreement between the Company and its employees. Refusal to complete or sign this document will result in a withdrawal of any offer of employment.
(NAME OF COMPANY)
Applicant Name
Applicant Signature

Clear
Date

Month Day Year
Date
Witness
APPLICANT DRUG-TESTING CONSENT AND RELEASE
This form must be completed when employee is given conditional job offer.

Pursuant to my application for employment, I understand that all job offers are expressly conditioned upon submitting to and passing a drug test to detect the presence of illegal drugs or alcohol use. I hereby consent to submit to a urinalysis or other tests as required by FlaiR A/C (the Company) for the purposes of testing for the presence of illegal drugs or alcohol abuse. I agree that a clinic or laboratory approved by the Florida Agency for Health Care Administration may collect and test any specimens I provide for these tests. I further agree to authorize the release of the results of these tests to the Medical Review Officer employed or retained by the Company, to the of the Company, and to such other management personnel as may require this information on a need to know basis. My understanding is that any information derived from these tests will be confidential between the laboratory, the of the Company, and the Medical Review Officer, except as otherwise provided by law, or if I place the test or its results in issue in any administrative, legal, or other proceeding.

I further agree to release and hold the Company and its agents, employees and assigns, including the laboratory collecting and conducting these tests, harmless from any liability arising in whole or in part out of the collection or testing of the specimens I provide or from the use of the information derived from these tests in consideration of my employment application.

I have carefully read this Consent and Release form and understand it completely. I also understand that execution of this Consent and Release is a condition of employment with the Company and my refusal to sign will result in withdrawal of any offer of employment I may receive. I am signing this form voluntarily and have not been coerced nor placed under duress by any person.
Applicant
Date *

Month Day Year
Date
Applicant Name *
Applicant Signature *

Clear
Social Security #
Witness - 1
Print Name *
Signature *

Clear
Witness - 2
Print Name *
Signature *

Clear
In connection with my application for employment (including contract services), I understand that investigative background inquires are to be made including consumer, criminal, driving, and other reports. These reports will include information as to my character, work habits, performance and experience along with reasons for termination of past employment from previous employers. Further, I understand that you will be requesting information from various Federal, State, and National agencies which maintain records concerning my past activities relating to my driving, credit, criminal, and other experiences as well as claims involving me in the files of insurance companies. I authorize without limitations, this employer to furnish the above mentioned or any other findings associated with the background search to the Hotel Motel Association of Volusia County (Agent for Flair Air Conditioning) to by used by its officers, managers, agents, and assigns.

These reports are a necessary part of our review of your application and are used to verify or supplement information that you may have already provided us. Examples of the type of consumer reports we may order include: Motor Vehicle Report (MVR), Insurance Claim Report, and/or an Insurance Score based on the National Credit File.

All reports that are ordered are impartial and will be kept strictly confidential. Our sole interests in the reports are to be sure that each application is evaluated fairly. The information we obtain will only be used for business purposes. If you wish, we will provide you with the name, address, and phone number of any consumer reporting agency from whom we request a report. At your request, the consumer-reporting agency will provide you with a copy of the report.

IMPORTANT: The Public Records and commercially available data sources used on reports may have errors. Data is sometimes entered poorly, processed incorrectly and is general not free from defect. This system should not be relied upon as definitively accurate. Before relying on any data that this system supplies, it should be independently verified. National Data does NOT include all states in the United States, only those states that have a "Right to Know" policy. Many states are protective of personal data and will not permit release of information. For those states that DO have a "Right to Know" policy, requests list from Rockwood Credit & Background Screening. *For those states that DO NOT include "Right to Know" see the following: Delaware DE, Hawaii HI, Massachusetts MA, North Dakota ND, South Dakota SD, Vermont VT, West Virginia WV, Wyoming WY.
Property / Account Name
Signature *

Clear
Return report to Fax #
Date

Month Day Year
Date
PLEASE PRINT CLEARLY - ALL IS REQUIRED
Name *

First Name Middle Name Last Name
Address *

Current Address

Street Address Line 2

City State / Province

Postal / Zip Code
Social Security #
Date of Birth *

Month Day Year
Driver's License *
State Issued *
Race
Sex

Male Female
Last three (3) states lived
Employee Signature *

Clear
Date *

Month Day Year
*MUST HAVE PHOTO COPY OF DRIVERS LICENSE*
Name *
MEDICAL QUESTIONNAIRE

HAVE YOU HAD OR DO YOU HAVE ANY OF THE FOLLOWING (Check "Yes" or "No" after each question):
Disease of:
Brain

Yes No
Eyes

Yes No
Ears

Yes No
Nose

Yes No
Throat

Yes No
Heart

Yes No
Lungs

Yes No
Stomach

Yes No
Intestines

Yes No
Liver

Yes No
Spleen

Yes No
Gallbladder

Yes No
Kidneys

Yes No
Bladder

Yes No
Bone

Yes No
Joints

Yes No
Back (Spine)

Yes No
Skin

Yes No
Lymph Nodes

Yes No
Tuberculosis

Yes No
Bronchitis

Yes No
Nephritis

Yes No
Malaria

Yes No
Cancer or Tumors

Yes No
Rheumatic Fever

Yes No
Asthma

Yes No
Arthritis

Yes No
Genitals

Yes No
Frequent Headaches

Yes No
Deafness

Yes No
Running Ears

Yes No
Freq. Sore Throat

Yes No
Frequent Colds

Yes No
Fainting Spells

Yes No
Chest Pains

Yes No
Shortness of Breath

Yes No
Chronic Cough

Yes No
Cough up Blood

Yes No
Palpitations

Yes No
Allergies

Yes No
Poor Appetite

Yes No
Chronic Indigestion

Yes No
Recurrent Vomiting

Yes No
Diabetes

Yes No
Nervous Breakdown

Yes No
Painful Flat Feet

Yes No
Hepatitis

Yes No
Did you hear well?

Yes No
Vomiting of Blood

Yes No
Paralysis

Yes No
Hay Fever

Yes No
Rheumatism

Yes No
Chronic Constipation

Yes No
Black or Bloody Bowel Movement

Yes No
Frequent or Painful Urination

Yes No
Blood in Urine

Yes No
Swollen Ankles

Yes No
High Blood Pressure

Yes No
Jaundice

Yes No
Hernia (Rupture)

Yes No
Stomach Ulcers

Yes No
Pneumonia

Yes No
Pleurisy

Yes No
Kidney Stones

Yes No
Hemorrhoids

Yes No
Convulsions

Yes No
Backaches

Yes No
Chronic Sinus Infection

Yes No
Injuries
Operations
If you have answered "yes" to any of the questions above, please explain
Have you ever received any pension, insurance payments or compensation for an injury or illness? Explain.
Have you ever been treated for back trouble or stomach trouble?
Have you ever been treated for blood disease?
Do you condsider yourself to be in good health?
Have you every been hospitalized?

Yes No
If yes, please explain.
Florida drivers license number
Have you every received a traffic violation?

Yes No
If yes, please given details
Have you ever been arrested?

Yes No
If yes, please given details
I authorize investigation of all statements contained in the application and certify that they are correct.
Date *

Month Day Year
Date
Signature *

Clear
Should be Empty:

Application for Employment

PLEASE PRINT

Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department.

Address

Employment History

Skills and Qualifications

Educational Background

References

In Case of Emergency Notify

APPLICANT DRUG-TESTING CONSENT AND RELEASE

Applicant

Witness - 1

Witness - 2

MEDICAL QUESTIONNAIRE