APPLICATION FOR EMPLOYMENT



APPLICATION FOR EMPLOYMENT“Under Maryland Law, an Employer may not require or demand, as a condition of employment, prospective employment, or continued employment, that an individual submit to or take a Lie Detector or similar test. An employer who violates this law is guilty of a misdemeanor and subject to a fine not exceeding $100.”We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.Note: Incomplete and/or applications that are not legible will not be accepted. (PLEASE PRINT IN CAPITAL LETTERS)Position(s) Applied ForDate of ApplicationHow Did You Learn About Us? (circle)Advertisement Friend Walk-In OtherEmployment Agency Relative (who)Last Name First NameMiddle NameAddress Number StreetCity State Zip CodeTelephone Numbers) : Home: Work:Cellular:Social Security NumberIf you are under 18 years of age, can you provide required proof of your eligibility to work? __________________Have you ever filed an application with us before? Have you ever been employed with us before? ________________Do you have friends/family working for us? If yes, give full names: ___________________________Do you know friends/family who worked for us before, if yes, give full names: __________________Are you currently employed? _____________________________________________________________________May we contact your present employer? ____________________________________________________________Yes No N/AIf Yes, who is your current employer? _______________________________________________________Address: _______________________________________________________________________________________Phone Number: __________________________________________________________________________________Name of Supervisor: ______________________________________________________________________________Are you prevented from lawfully becoming employed in this ____Yes _____Nocountry because of Visa or Immigration Status?(Proof of citizenship or immigration status will be required upon employment)On what date would you be available for work? _____________________________________________________Are you available to work: Part Time (indicate days/hours)__________________________________________________________________Full Time: (indicate hours)_____________________________________________________________________Do you have a valid driver's license? _______ _________ Yes No(If yes, we need a copy of your license after verification)Do you have a criminal background?________________________________________Yes __ NoIf Yes, please explain. If you need additional space, please use the last page of this application:EducationName and Address of SchoolCourse of StudyYears CompletedDiploma or DegreeElementary SchoolHigh SchoolUndergraduate CollegeGraduate ProfessionalOther (Specify)Describe any DDA/DHR training that you received: (We will need proof of Training)Name of TrainingDate ReceivedWhere?jDescribe additional training received in the United States, if any: ( We will need proof of training received)Name of TrainingDate ReceivedWhere did you receive training?List Professional, trade, business or civic activities and offices held.You may exclude membership which would reveal gender, race, religion .national origin, age, ancestry, disability or other protected status:Additional InformationOther QualificationsSummarize special job-related skills and qualifications acquired from employment or other experienceComputer Skills,if any (Applicable to office-related work only)PC programsQuick books Excel Other (list)WordLotus 1-2-3 Other SoftwareWord PerfectWorksInternetPublisherEmployment ExperienceStart with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.(1) EmployerDates EmployedWork PerformedFromMm/yyToMm/yyAddress: (full)Telephone Number(s)With ext.Hourly Rate/SalaryJob TitleSupervisorStartingFinalReason for Leaving(2) EmployerDates EmployedAddress (full)FromMm/yyToMm/yyTelephone NumbersWith ext.Job TitleSupervisorHourly Rate/SalaryReason for leavingStartingFinal(3) EmployerDates EmployedAddress (full)FromMm/yyToMm/yyTelephone Number(s)With ext.Job TitleSupervisorHourly Rate/SalaryReason for LeavingStartingFinal(4) EmployerDates EmployedAddress (full)ToMm/yyFromMm/yyTelephone Number(s)With ext.Job TitleSupervisorHourly Rate/SalaryReason For LeavingStartingFinalState any additional information you feel may be helpful to us in considering your application.Note to Applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities in the job or occupation for which you applied? A description of the activities involved in such a job or occupation is attached.YesNo* References . The name, address below should match Employment Reference Letters to be received by this company if you are selected. You must present the Letters (3) before you will be authorized to start work.1. Name: Job Title:Name of the Company: Address:Phone: ( )2. Name: Job Title:Name of the Company: Address:Phone: ( )3. Name: Job Title:Name of the Company: Address:Phone: ( )* All (3) references should be from your past employer/s . If this is your first employment, we would require (1) reference from your college/school principal and another reference from a teacher at your college/school.We will not accept references from friends and relatives of the applicant. CCI employees should not be used as references.FOR PERSONNEL DEPARTMENT USE ONLYPosition(s) Applied For Is Open Yes NoOther Positions Can Be Considered For: Date:NOTES:Applicant's StatementI 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.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 the 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: Interviewed by RemarksFOR PERSONNEL DEPARTMENT USE ONLY Interviewer Date __Selected a Yes NoDate of EmploymentJob Title ___________ Hourly Rate/ Salary_Department_______________By_________________________Name and TitleDateNOTES:Employment Reference Form(To be completed by applicant)I,___________________________, hereby authorize _________________________________________Address:_____________________________________________________________________________Phone: __________________________________. Fax:______________________________________To release all pertinent information to CCI, Inc.Signature of Applicant: _____________________________________Date:_______________________(To be completed by previous employer)Dates of Employment: From: _________________________To:____________________Last Position Held: ___________________________________________________________Current status (employed, terminated, resigned):____________________________________Will you re-hire: (yes/no):______________________________________________________Comments:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Information given by: Full Name__________________________________________________________Title:_______________________________________________Date:___________ __________Name of Company:_____________________________________________________________________Address:_____________________________________________________________________________Phone:________________________________________ Fax:___________________________________>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>Reference Acquired Via: Phone: _____________?Fax:._________ Mail: ________________________Name of CCI, Inc. Staff receiving info:______________________________ Date:__________________ ................
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