Employment Application

General Information

To process your application, all questions must be answered. If a question does not apply, write N/A.

Today’s date

Position applying for(Required)

Name(Required)

Current Address(Required)

Are you known by another name?

Yes or No

If so, list here

List your address for the past three (3) years

Address

Street

City

State

Zip

How long here?

Additional Information

Type of employment

Full-Time

Part-Time

Temporary (summer work, etc.)

Date available to start work

Are you known by another name?

Yes or No

Home Phone

What are your salary / hourly rate expectations ?

How were you referred to us ?

Have you ever applied here or worked here before ?

Yes

If yes, list date(s)

This employer participates in the E-Verify program. If hired, verification will be required consistent with federal law.

Are you legally authorized to work in the United States?

Yes

Employment History

List your employment history for the last 10 years. Start with your present or most recent employer and include self-employment, military service, summer and part-time jobs. If a question does not apply, write N/A.

If presently employed, why do you wish to change positions?

Current or Previous Employers

Present / Previous Employer

Company Name

Employment Start Date

Employment end date

Street

City

State

Zip

Name & Title of Supervisor

Phone

May we contact this Employer?

Yes

Your position and duties:

Reason for leaving

Unemployment

Please account for any periods of unemployment of one (1) month duration or more since you left school to the present.

Start Date

End Date

Please State What You Were Doing

From (Mo / Year)

To (Mo / Year)

Please State What You Were Doing

From (Mo / Year)

To (Mo / Year)

Please State What You Were Doing

Start Date

End Date

Please list what you were doing during this time period

Education

School Name

School Address

Type of School (HS, college, trade, other)

Major, Course or Subject Studied

No. of years completed

Degree / Certificate

GPA

If you did not graduate, when did you leave school/college, and why?

Extracurricular

List any scholastic honors, offices held, and/or activities in high school or college. Please do not list organizations that reveal race, creed, color, national origin, religion, age, or sex.

List any foreign language capabilities

Industry Related Courses, Licenses or Certifications

List any courses, licenses or certifications you have completed which will aid this Company in evaluating your qualifications for the position you are seeking. (For example: If applying for a clerical, construction laborer, or supervisory position, note training such as word processing or computer, safety, or management training.)

School Name or Course

School Address

Type of School (HS, college, trade, other)

From: MM/YYYY - To: MM/YYYY

Content of Course

Final Grade / License / Certification

If you did not graduate, when did you leave school/college, and why?

If yes, when, where, and what course(s):

Special Skills

List any special skills that you feel are relevant or related to the position for which you are applying. You may wish to include civic / community activities, professional societies, hobbies, sports, or special training such as bookkeeping, software knowledge, operation of equipment or other applicable skills. Please do not list organizations or activities which reveal, race, religion, age, sex, national origin or ancestry, sexual orientation, disability or political persuasion.

References

Please list (3) references other than previous employers, supervisors or relatives. By providing this information, you give this Company permission to contact the individuals listed.

Name

Phone Number

Address

Please read before signing

By signing your name below, you acknowledge and certify the following:

All statements made by me on this application are true and complete to the best of my knowledge.
I have withheld nothing that would affect this application unfavorably.
Any offer I may receive from the Company is contingent upon my successful completion of the Company’s total pre-employment screening process.
I understand misrepresentations or omissions may be cause for rejection or may be cause for subsequent dismissal if hired.

I understand that nothing contained in this application or in the interview process is intended to create an employment contract between the Company and myself. Should this application result in my employment, it will be an at-will relationship. I have a right to terminate my employment at any time and for any reason and the Company retains the same right. I agree to conform to the rules and regulations of the Company. I further understand that no representative of the Company other than a Senior Officer of the Company has any authority to enter into any agreement with me for any specified period or to guarantee some other personnel move or benefit. I also understand that any such agreement, if made, shall not be enforceable unless it is in writing and signed by me, and a Senior Officer of the Company.

I understand that past employers, educational institutions and/or the military may be contacted for references. I authorize any such organization to provide the requested information. I further release and forever discharge the Company, its agents, its employees, and the individuals, companies, and health care providers contacted by this Company as part of its inquiries and investigations, from any and all claims, demands, damages, actions, causes of action, or suits of any kind or nature whatsoever arising from the Company’s inquiries and investigation of my credentials and information in connection with my application.

I understand that, where permissible under applicable federal, state, or local law, I may be subject to a pre-employment drug test after receiving a conditional offer of employment and must receive a negative result for illegal drug use before being permitted to commence work for ReAgg.

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 POLYGRAPH EXAMINATION OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $100.

I understand this entire statement applies to the period before, or after, I may be employed. I hereby acknowledge that I have read and understand each of the above statements. I authorize release of information about me to this Company.

Printed Name of Applicant

Date

Acceptance(Required)

I agree to the Terms and Conditions

Employment Application