Maymead Employment Application

Employment Application Form
Applicant Log:

(Required by U.S. Department of Labor) This section must be completed before your application will be considered.
Todays Date *

Month Day Year
Date
Full Name *

First Name Middle Name Last Name
EEO Code
Address (Required) *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Date of Birth (Required) *

Month Day Year
Phone Number (Required) *

Area Code Phone Number
E-mail
Emergency Contact: *

First Name Last Name
Emergency Contact Phone Number: *

Area Code Phone Number
Emergency Contact Relationship: *
General Information:
What position(s) are you applying For?
Last 3 companies you have worked for:
Nickname (If applicable)
Have you filled out an application with us before?

Yes No
If you've applied previously, when?

Month Day Year
Date
Have you been employed by this company before?

Yes No
If employed by us previously, when?

Month Day Year
Date
Are you a US Citizen?

Yes No
If you are not a US Citizen, are you here under a visa?

Yes No Neither
What date would you be available for employment?

Month Day Year
Date
Rate of pay expected:
Hourly or Salary?

Hourly Salary
United State Military Service Record
Were you in the armed services?

Yes No
If served in the armed forces, when?
If you served in the armed forces, please describe the job experience gained in the service.
Are you a "Vietnam Era" veteran?

Yes No
Are you a "special-disabled" veteran?

Yes No
Type of discharge?
Education:
Name of High School:
City and state where your High school was located:
Highest grade completed
If you did not finish high school, have you obtained your GED?

Yes No
Name of college if attended:
Location of college:
Number of Years Attended
Graduated College?

Yes
Area of Study/Degree
Please list below any additional educational and/or technical vocational training you have received that would be applicable to the position you are seeking
Criminal Record
Have you been convicted of a crime or pleaded nolo contendre (no contest) to a criminal offense (other than traffic violations) in the past ten (10) years? If yes, complete the following and list all instances even if adjudication was withheld.

Yes No
Name at time of Conviction #1
Date of Conviction #1

Month Day Year
Date
Charge of Conviction #1
Sentence of Conviction #1
Name at time of Conviction #2
Date of Conviction #2

Month Day Year
Date
Charge of Conviction #2
Sentence of Conviction #2
Employment History
List your current or most recent employer and the type of work they do.
Enter NONE if not employed
Current/Previous Company address:
Current/Previous Company phone number:
Start date with this company

Month Day Year
Date
May We Contact?

Yes No
Date your employment ended:

Month Day Year
Date
List your last (or current) hourly or salary rate:
Your last (or current) immediate supervisor:
Supervisor phone number:
Other supervisors you worked for in this company?
Reason for leaving (or why your are looking to leave if still employed.)
List all titles, duties and length of time you performed them for this company:
Employee Acknowledgements

IMPORTANT: You must read the following statements carefully. Put your initials by each statement in the space provided.
This company is an equal opportunity employer and considers all applicants for employment without regard to race, color, sex, religion, national origin, age, veteran status, or mental or physical disability (unless the disability prevents acceptable performance or creates a safety hazard with the work involved). *
PLEASE INITIAL IN THE BOX
I understand and agree that because employment at this company is based on mutual consent, the right of the employment relationship "at will" is recognized and affirmed as a condition of employment irrespective of any other company policy, rule, or regulation. *
PLEASE INITIAL IN THE BOX
Equal employment opportunity voluntary questionnaire

To help us comply with federal and state equal employment opportunity record keeping, reporting, and other legal requirements, we are requesting the information below. The information is used for statistical purposes only. Submittal of this information is strictly voluntary.It is the policy of Maymead, Inc. to assure that applicants and employees are treated without regard to their race, religion, sex, age, color, national origin, disability, or veteran status. Such action shall include: employment, upgrading, demotion, or transfer; recruitment or 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.
Date

Month Day Year
Date
Phone Number

Area Code Phone Number
Name

First Name Middle Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Sex

Male Female
Race/Ethnic Group

White Black Hispanic American Indian or Alaskan Native Asian or Pacific Islander
Date of Birth

Month Day Year
Date
Age
How were you referred to our company?

Walk-in Ad Agency Employee Referral
This employer is a government contractor subject to section 503 of the rehabilitation act of 1973 and section 402 of the Vietnam era veterans readjustment assistance act of 1974 which requires government contractors to take affirmative action to employ and advance in employment qualified disabled veterans, veterans of the Vietnam era and the handicapped persons. If you are covered by these programs and would like to be considered under the affirmative action program, please tell us. providing this information is voluntary and refusal to provide it will not subject you to discharge or disciplinary treatment if you are employed. Information obtained concerning individuals relating to these questions shall be kept confidential except that supervisors and managers may be informed regarding restrictions of the work duties of disabled veterans and/or handicapped persons and regarding necessary accommodations; also, first aid personnel may be informed when and to the extent appropriate if the conditions might require emergency treatment.
Are you a Vietnam era veteran: (served on active duty for more than 180 days, any part of which occurred between August 5, 1964 and May 7, 1975):

Yes No
If yes above, what is your VA disability rating?
Do you have any physical, mental, or medical impairment or disability which would limit your job performance in the job for which you are applying? Please note that furnishing this information will not necessarily result in rejection for the position, but may enable the company to determine if there are other positions that you can perform or if you will be able to execute the job you are seeking with reasonable accommodations.

Yes No
If "yes" above, please explain:
Enter Your Name To Sign

First Name Middle Name Last Name
Voluntary Self-Identification of Disability:

WHY ARE YOU BEING ASKED TO COMPLETE THIS FORM? We are a federal contractor or subcontractor required by law to provide equal employment opportunity to qualified people with disabilities. We are also required to measure our progress toward having at least 7% of our workforce be individuals with disabilities. To do this, we must ask applicants and employees if they have a disability or have ever had a disability. Because a person may become disabled at any time, we ask all of our employees to update their information at least every five years.Identifying yourself as an individual with a disability is voluntary, and we hope that you will choose to do so. Your answer will be maintained confidentially and not be seen by selecting officials or anyone else involved in making personnel decisions. Completing the form will not negatively impact you in any way, regardless of whether you have self-identified in the past. For more information about this form or the equal employment obligations of federal contractors under Section 503 of the Rehabilitation Act, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.
How Do You Know If You Have a Disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially
limits a major life activity, or if you have a history or record of such an impairment or medical condition. Disabilities
include, but are not limited to:

Autism
Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, or HIV/AIDS
Blind or low vision
Cancer
Cardiovascular or heart disease
Celiac disease
Cerebral palsy
Deaf or hard of hearing
Depression or anxiety
Diabetes
Epilepsy
Gastrointestinal disorders, for example, Crohn's Disease, or irritable bowel syndrome
Intellectual disability
Missing limbs or partially missing limbs
Nervous system condition for example, migraine headaches, Parkinson’s disease, or Multiple sclerosis (MS)
Psychiatric condition, for example, bipolar disorder, schizophrenia, PTSD, or major depression
Please check one of the boxes below:

Yes, I have a disability. No, I don't have a disability. I don't wish to answer.
Name

First Name Last Name
Date

Month Day Year
Date
Public Burden Statement

According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.
Cover Letter & Resume (Optional):

You may upload/attach a resume or cover letter to submit with your application.
Cover Letter
Resume
Send Application:
By clicking the submit button below, I cerity that all of the information provided by me on this application is true and complete, and I understand that if any false information, ommissions, or misrepresentations are discovered, my application may be rejected and, if I am employed, my employement may be terminated at any time. In consideration of my employment, I agree to conform to the company's rules and regulations, and I agree that my employment and compenstation 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.
Please verify that you are human *
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Employment Application Form

Applicant Log:

General Information:

United State Military Service Record

Education:

Criminal Record

Employment History

Employee Acknowledgements

Equal employment opportunity voluntary questionnaire

Voluntary Self-Identification of Disability:

Cover Letter & Resume (Optional):

Send Application: