PDF Wayne Densch, Inc.
WAYNE DENSCH, INC.
Wholesalers of Anheuser-Busch Beers
An Equal Opportunity Employer
APPLICATION FOR EMPLOYMENT
PERSONAL INFORMATION
DATE
NAME
LAST
PRESENT ADDRESS
NUMBER
FIRST STREET
MIDDLE
HOME OR NEAREST PHONE
PREVIOUS ADDRESS
IF AT PRESENT ADDRESS LESS THAN ONE YEAR
CITY NUMBER
CITY
STREET
STATE
ZIP
STATE
ZIP
SOCIAL SECURITY NUMBER
ARE YOU OVER THE AGE OF 18?
YES
NO
APPLICATION ATTESTATION
I declare and affirm under penalty of perjury that I am, (check the appropriate box):
A citizen or national of the U.S.
An alien authorized to work in the United States under the U.S. Immigration and Nationality act.
An alien lawfully admitted for U.S. permanent residence.
Position applied for:
How soon could you report to work?
Is there anything that will prevent you from performing the essential functions of the position or positions for which you are applying with or
without reasonable accommodation?
Yes
No
If yes, please explain:
Type of employment desired?
Full Time
Have you ever applied to this company before?
Have you ever been previously employed by this company before?
Part Time Yes
Yes
Salary desired? No If yes, give date: No If yes, when, where, and in what position:
Are you willing to work:
Nights?
Yes
No
Weekends?
Yes
No
Shift Work?
Yes
No
Who do you know that works for this company? 1.
2.
Have you ever been convicted of a crime?
Yes
No
If yes, please explain:
Have you ever been discharged from or requested to resign from a position?
Yes
No
If yes, please explain:
Are you currently employed?
Yes
No
If yes, why do you want to make a change?
Have you ever held a position of trust (handling money or confidential material)?
Yes
No
TYPE OF SCHOOL ELEMENTARY
SCHOOL NAME
EDUCATIONAL INFORMATION
SCHOOL LOCATION
DATES ATTENDED
GRADUATION DATE
HIGH SCHOOL/GED
TECHNICAL OR VOCATIONAL
JUNIOR COLLEGE
COLLEGE OR UNIVERSITY GRADUATE
SCHOOL
OTHER, INCLUDE
MILITARY SCHOOLS
PLEASE LIST MACHINES YOU CAN OPERATE OR JOB RELATED SKILLS YOU ARE PROFICIENT IN:
MACHINE OR SKILL
YEARS EXPERIENCE
MACHINE OR SKILL
YEARS EXPERIENCE
VEHICLE OPERATOR LICENSE INFORMATION
VEHICLE
ISSUE
OPERATOR STATE
LICENSE NUMBER
CDL LICENSE NUMBER
LICENSES
HELD
YOU MUST COMPLETE THIS SECTION IF THE POSITION APPLIED FOR REQUIRES USE OF A COMPANY VEHICLE
PRIVATE VEHICLE LICENSE NUMBER
EXPIRATION DATE
VEHICULAR EQUIPMENT YOU HAVE OPERATED
YOU MUST COMPLETE THIS SECTION IF THE POSITION APPLIED FOR REQUIRES USE OF A COMPANY VEHICLE
HAVE YOU BEEN DRIVING PROFESSIONALLY FOR THE PAST FIVE YEARS?
YES
NO
TICKETS YOU HAVE HAD (MOVING VIOLATIONS ONLY)
YOU MUST COMPLETE THIS SECTION IF THE POSITION APPLIED FOR REQUIRES USE OF A COMPANY VEHICLE
CITY/STATE
DATE OF INFRACTION
INFRACTION (DESCRIBE)
PENALTY YOU RECEIVED
ACCIDENTS YOU HAVE BEEN INVOLVED IN (PAST FIVE YEARS)
YOU MUST COMPLETE THIS SECTION IF THE POSITION APPLIED FOR REQUIRES USE OF A COMPANY VEHICLE
DATES
CITY/STATE WHERE ACCIDENT OCCURRED
WHAT HAPPENED IN THIS ACCIDENT?
WERE YOU CHARGED?
LIST ALL EMPLOYERS IN ORDER WITH THE LAST OR PRESENT EMPLOYER(S) LISTED FIRST
INCLUDE PART-TIME EMPLOYERS (ATTACH ADDITIONAL SHEET IF NECESSARY OR INCLUDE RESUME IN ADDITION TO INFORMATION BELOW)
DATES
NAME, ADDRESS AND PHONE NO. OF EMPLOYER
RATE OF PAY
SUPERVISOR'S NAME AND TITLE REASON FOR LEAVING
FROM
START
TO
FINISH
JOB TITLE
MAY WE INQUIRE OF THIS EMPLOYER
YES
NO
DESCRIBE IN DETAIL THE WORK OR JOB YOU PERFORMED
ARE YOU ELIGIBLE FOR REHIRE BY THIS EMPLOYER
YES
NO IF NO, WHY?
DATES
NAME, ADDRESS AND PHONE NO. OF EMPLOYER
FROM
TO
JOB TITLE DESCRIBE IN DETAIL THE WORK OR JOB YOU PERFORMED
RATE OF PAY
SUPERVISOR'S NAME AND TITLE
START
FINISH MAY WE INQUIRE OF THIS EMPLOYER
REASON FOR LEAVING
YES
NO
ARE YOU ELIGIBLE FOR REHIRE BY THIS EMPLOYER
YES
NO IF NO, WHY?
DATES
NAME, ADDRESS AND PHONE NO. OF EMPLOYER
FROM
TO
JOB TITLE DESCRIBE IN DETAIL THE WORK OR JOB YOU PERFORMED
RATE OF PAY
SUPERVISOR'S NAME AND TITLE
START
FINISH MAY WE INQUIRE OF THIS EMPLOYER
REASON FOR LEAVING
YES
NO
ARE YOU ELIGIBLE FOR REHIRE BY THIS EMPLOYER
YES
NO IF NO, WHY?
DATES
NAME, ADDRESS AND PHONE NO. OF EMPLOYER
FROM
TO
JOB TITLE DESCRIBE IN DETAIL THE WORK OR JOB YOU PERFORMED
RATE OF PAY
SUPERVISOR'S NAME AND TITLE
START
FINISH MAY WE INQUIRE OF THIS EMPLOYER
REASON FOR LEAVING
YES
NO
ARE YOU ELIGIBLE FOR REHIRE BY THIS EMPLOYER
YES
NO IF NO, WHY?
PLEASE EXPLAIN BELOW ALL GAPS IN YOUR EMPLOYMENT WHICH HAVE EXCEEDED ONE (1) MONTH FROM THE DATE YOU BEGAN YOUR MOST RECENT JOB TO THE PRESENT
HAVE YOU WORKED UNDER A DIFFERENT NAME FOR ANY OF THESE EMPLOYERS?
YES
NO
IF "YES", PLEASE IDENTIFY THE EMPLOYER AND STATE THE NAME:
PERSONAL REFERENCES (DO NOT INCLUDE FORMER EMPLOYERS, SUPERVISORS, OR RELATIVES)
NAME
PHONE # H
W
OCCUPATION
NAME
PHONE # H
W
OCCUPATION
NAME
PHONE # H
W
OCCUPATION
This application provides information which enables us to determine whether an applicant has the qualifications and experience to be given additional consideration for employment. In most cases, circumstances will prevent a preliminary interview; therefore, the conscientious completion of this form is necessary inasmuch as it will supply much of the information normally covered in such a session. At the appropriate time you will be required to prove your citizenship or, if not a citizen, your eligibility for employment. All statements made by applicants for employment on this application form will be carefully checked for accuracy. Wayne Densch, Inc. offers equal employment opportunities to all persons without regard to race, color, religion, age, sex, marital status, national origin, disability or veteran status. The use of this application does not indicate the availability of positions at nor obligate Wayne Densch, Inc. in any way. The application shall remain in an active file for a period of six months from the date of this application. I certify and affirm that all of the information furnished on this application is true, complete and correct. I understand and agree that any falsification, misrepresentation, misleading statement, or omission of fact on either this application or, during the pre-employment process shall be sufficient cause for; (1) my not being offered employment, or; (2) my dismissal at any time if I am employed. I authorize Wayne Densch, Inc. to verify all information on this application including but not limited to; employment history, educational background, credit records and motor vehicle records, and to acquire any and all criminal history record information pertaining to me which may be in the files of any Federal, State, or Local criminal justice agency in Florida or any other States. I understand and agree that because of the nature of the business conducted by Wayne Densch, Inc., that all information whether written, spoken, or otherwise communicated to me or obtained by me; and any information in any and all files and records of any and every description, relating to the business of Wayne Densch, Inc. or to any person, persons, company or corporation with whom Wayne Densch, Inc. has dealings, shall constitute privileged matters and shall be treated by me in a strictly confidential manner. I fully understand and agree that, if employed by Wayne Densch, Inc., I am not authorized to and shall not at any time communicate and/or reveal any business information, records, or files or any other matters relating to the business of Wayne Densch, Inc. to any person or persons within Wayne Densch, Inc. or to any person, persons, company or corporation outside Wayne Densch, Inc. I also understand and agree that any violation of this confidentiality shall constitute grounds for termination.
I understand and agree that if employed by Wayne Densch, Inc., I shall comply with all rules and regulations as set forth in Wayne Densch, Inc., policy manual and any other communication distributed to employees by Wayne Densch, Inc. I understand and agree that employment by Wayne Densch, Inc. may be conditioned upon an acceptable fitness for duty medical and health evaluation which may include a physical examination paid for by Wayne Densch, Inc. and conducted by a physician and/or medical organization selected by Wayne Densch, Inc. I understand and agree that employment by Wayne Densch, Inc. may be conditioned upon an acceptable drug and/or alcohol screening test result, such screening to be conducted by a physician and/or medical organization selected by Wayne Densch, Inc. I further agree to submit, at any reasonable time during my employment, and without prior notice, to a drug and/or alcohol screening test. I understand and agree that refusal on my part to take a requested drug and/or alcohol screening test may result in my immediate discharge. I further understand and agree that a positive drug and/or alcohol screening test may result in my immediate discharge.
I authorize Wayne Densch, Inc. to supply my employment record, in whole, or in part, to any prospective employer, government agency, and/or other party with a legal interest, and I release and hold harmless any and all such parties from any and all liability for direct or consequential damages resulting from such release and/or disclosure. I understand that nothing in this employment application, in Wayne Densch, Inc.'s statements or personnel guidelines, or in my communication with any Wayne Densch, Inc. official is intended to create an employment contract between Wayne Densch, Inc. and me. I also understand that Wayne Densch, Inc. has the right to modify its policies without giving me any notice of the change(s). No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon Wayne Densch, Inc. unless it is made in writing and signed by a Wayne Densch, Inc. officer. I understand that if an employment relationship is established, I have a right to terminate my employment at any time. I also understand that Wayne Densch, Inc. retains the right to terminate my employment at any time.
I have read and, understand the foregoing, and by my signature below, accept the foregoing terms and conditions for employment, if offered such a position. I attest also by my signature below that all the information I have provided on this application is true and complete.
Please make sure you have completed each section.
DATE
SIGNATURE OF APPLICANT PRINTED NAME OF APPLICANT
Equa l Employment Opportunity Self ID Survey
Ap p lic a nts a nd emp lo yees a re trea ted w ithout reg a rd to ra c e, c o lor, religion, sexua l orienta tion, g end er, na tiona l orig in, c itizenship sta tus (unless req uired b y a g overnment c ontra c t), a ge , ma rita l or vetera n st a tus, p hysic a l or menta l d isa b ility, or a ny other le ga lly p rotec te d sta tus d uring eve ry a sp ec t o f the e mp lo yment p roc ess.
So lely to he lp us c o mp ly with c erta in g overnme nta l rec o rd keep ing a nd rep orting req uirements fo r the a d ministra tion of c ivil rig hts la w s a nd reg ula tions, p lea se c omp le te the surve y b elow . Sub mission o f this informa tion is volunta ry a nd refusa l to p rovid e it will not sub jec t you to a ny a d verse trea tme nt. This info rma tion w ill not b e used for hiring , p la c eme nt, or o ther d ec isions rela ted to the te rms a nd c o nd itions o f emp loyment. This d o c ument w ill b e ke p t in a c onfid entia l file, sep a ra te from a p p lic a nt a nd p erso nnel files. When rep orted , d a ta will no t id entify a ny sp ec ific ind ivid ua l.
YOUR COOPERATION IS VOLUNTARY
INCLUSION OR EXCLUSION OF ANY DATA WILLNOTAFFECTANY EMPLOYMENTDECISION Plea se c omp lete the follow ing informa tion. Plea se p rint.
Last Na me:
First Na me:
Da te:
Job Title:
Gender Ma le
Fema le
Ethnic ity - Are you Hisp a nic or La tino? (A person of Cub a n, Mexic a n, Puerto Ric a n, South or Centra l Americ a n, or other Sp a nish c ulture or origin, rega rd less of ra c e.)
Ye s
No
Ra c e - If you a re not Hisp a nic or Latino, p lea se selec t the a p p rop ria te ra c e c a tegory.
White (Not Hisp a nic or La tino) - A p erson ha ving origins in a ny of the origina l p eoples of Europ e, the Mid d le Ea st, or North Afric a .
Bla c k or Afric an Americ a n (Not Hispa nic or La tino) ? A p erson ha ving origins in a ny of the Bla c k ra c ia l group s of Afric a .
Na tive Haw a iia n or Other Pa c ific Island er (Not Hisp a nic or La tino) - A p erson ha ving origins in a ny of the origina l p eoples of Ha w a ii, Gua m, Sa moa , or other Pa c ific Island s.
Asia n (Not Hisp a nic or La tino) - A p erson ha ving origins in any of the origina l p eop les of the Fa r Ea st, Southea st Asia, or the India n sub c ontinent inc lud ing, for exa mp le, Ca mb od ia , China , Ind ia , Ja p an, Korea , Ma la ysia , Pa kista n, the Philip p ine Isla nd s, Tha ila nd , a nd Vietna m.
Americ a n Ind ia n or Ala ska Na tive (Not Hisp a nic or La tino) - A p erson ha ving origins in a ny of the original p eop les of North a nd South Americ a (inc lud ing Centra l Americ a ), a nd w ho ma inta ins trib a l a ffiliation or c ommunity a tta c hment.
Two or More Ra c es (Not Hisp a nic or La tino) - p ersons who id entify w ith more tha n one of the a b ove five ra c es.
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