Name:
*
First Name
Last Name
Date:
*
-
Month
-
Day
Year
Date
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
*
Cell Phone
*
Email
*
example@example.com
Social Security # (optional):
Drivers' License # (optional):
On what date would you be available for work?
*
-
Month
-
Day
Year
Date
Desired Wage/Salary
*
Are you legally authorized to work in the United States?
*
Yes
No
Have you ever been convicted of a felony?
*
Yes
No
If yes, please describe circumstances:
Have you been involuntarily terminated or asked to resign from any position?
*
Yes
No
If yes, please describe circumstances:
If selected for employment, are you willing to submit to a pre-employment drug screening test?
*
Yes
No
EDUCATION
*
School Name
Location
Years Attended
Degree Earned
Major
1
2
3
4
5
Other training, certifications, or licenses held:
*
List other information pertinent to the employment you are seeking:
*
EMPLOYMENT (starting with most recent)
1. Employer
Dates Employed
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
Job Title
Supervisor
Starting Salary
Ending Salary
Duties Performed
Reason for Leaving
2. Employer
Dates Employed
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
Job Title
Supervisor
Starting Salary
Ending Salary
Duties Performed
Reason for Leaving
3. Employer
Dates Employed
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
Job Title
Supervisor
Starting Salary
Ending Salary
Duties Performed
Reason for Leaving
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EMPLOYMENT (continued)
Have you signed any non-competition or non-solicitation agreement or any other kind of agreement with any other employer that might restrict you from working for this Company (you will be required to furnish a copy of the agreement if you are being considered for hire)?
*
Yes
No
MILITARY SERVICE (complete only if you served in the military)
Branch of Service:
Number of Years /Months of Service:
Rank at Discharge:
Date of Discharge:
Describe any military skills, training or experience you believe are relevant to the job you applied for:
REFERENCES
Please list two references: one job-related and one professional/character. None can be relatives or family members.
1. Name
*
Phone #
*
How are you acquainted with this reference?
*
2. Name
*
Phone #
*
How are you acquainted with this reference?
*
ACKNOWLEDGMENT AND AUTHORIZATION
I certify that answers given herein are true and complete to the best of my knowledge.
I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.
I understand that I may be required to qualify for employment based on additional employment criteria. For example, I may be required to take job-related tests; take a driver's examination or take a pre-employment drug test. If I am offered employment or start work before any required test is completed, I understand that my employment is contingent upon satisfactory results on all required tests.
This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.
I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.
In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Employer.
Signature of Applicant
*
Date
*
-
Month
-
Day
Year
Date
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Program Registration and
Apprenticeship Agreement
Office of Apprenticeship
U.S. Department of Labor
Employment and Training Administration
Voluntary Disability Disclosure
OMB No. 1205-0223 Expiration Date: 07/31/2027
Please check one of the boxes below:
Disability Status
*
YES, I HAVE A DISABILITY (or previously had a disability)
NO, I DON'T HAVE A DISABILITY
I DON'T WISH TO ANSWER
Your name:
*
Date:
*
-
Month
-
Day
Year
Date
Why are you being asked to complete this form?
Because we are a sponsor of a registered apprenticeship program and participate in the National Registered Apprenticeship System that is regulated by the U.S. Department of Labor, we must reach out to, enroll, and provide equal opportunity in apprenticeship to qualified people with disabilities. [1] To help us learn how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for apprenticeship, any answer you give will be kept private and will not be used against you in any way.
If you already are an apprentice within our registered apprenticeship program, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our apprentices at the time of enrollment, and then remind them yearly, that they may update their information. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.
How do I know if I 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: blindness, deafness, cancer, diabetes, epilepsy, autism, cerebral palsy, HIV/AIDS, schizophrenia, muscular dystrophy, bipolar disorder, major depression, multiple sclerosis (MS), missing limbs or partially missing limbs, post-traumatic stress disorder (PTSD), obsessive compulsive disorder, impairments requiring the use of a wheelchair, and intellectual disability (previously called mental retardation).
[1] Part 30 - Equal Employment Opportunity in Apprenticeship. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor's Office of Apprenticeship website at https://www.apprenticeship.gov/eeo.
ETA 671 – Section II
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