APPLICATION FOR EMPLOYMENT EQUAL OPPORTUNITY EMPLOYER

Transcription

1 APPLICATION FOR EMPLOYMENT EQUAL OPPORTUNITY EMPLOYER 9641 Old Gentilly Road New Orleans, La PERSONAL INFORMATION Metro Disposal Inc., is an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including age, sex, color, race, creed, national origin, religious persuasion, marital status, political belief, or disability that does not prohibit performance of essential job functions. Date: Name: Last First Middle Maiden Present address:_ Permanent address: Telephone: ( ) Social Security: / / Cell phone: ( ) Are you 18 years or older: Federal law prohibits the employment of unauthorized aliens. All persons hired must submit satisfactory proof of employment authorization and identity (valid driver s license, birth certificates, green card, etc.) Within three days of being hired. Failure to submit such proof within the required time shall result in immediate employment termination. DESIRED EMPLOYMENT Position applied for: Date you can start: Salary desired: Are you employed now? If so may we contact your employer? Have you ever applied to this company before? Where and when? Have you ever worked for this company before? Where and when? Reason for leaving: Supervisor: Who referred you to this company? Employment agency Newspaper Friend State Employment office College Placement Walk-in Other EDUCATIONAL INFORMATION School Level (Name & Location) Number of years attended Did you graduate? Subject Studied Grammar School High School College Trade, business or correspondence school SPECIALTY INFORMATION Subject of special study or research work: Special training: Special skills:

2 FORMER EMPLOYEES Name of present or last employer: Address: Starting date:_ Leaving date: Job title: Weekly starting salary: Weekly final salary: May we contact your supervisor? Name of Supervisor: Title: Phone: Description of work: Reason for leaving: Name of present or last employer: Address: Starting date:_ Leaving date: Job title: Weekly starting salary: Weekly final salary: May we contact your supervisor? Name of Supervisor: Title: Phone: Description of work: Reason for leaving: Name of present or last employer: Address: Starting date:_ Leaving date: Job title: Weekly starting salary: Weekly final salary: May we contact your supervisor? Name of Supervisor: Title: Phone: Description of work: Reason for leaving: REFERENCES List three person not related to you, whom you have known at least one year. Name Address Phone Years Acquainted AUTHORIZATION I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise and release the company from all liability for any damage that may result from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. Applicant Signature Date

3 9641 Old Gentilly Road New Orleans, La NOTIFICATION FORM Regarding Consumer Report For employment purposes, we may obtain a consumer report for and/ or an investigative report about you. The Fair Credit Report Act gives you the specific rights. If we rely on the report for adverse action before taking the adverse action, we will give you a pre-adverse action disclosure that includes a copy of the document entitled A Summary Of Your Rights Under The Fair Credit Reporting Act. By signing your signature below, you hereby authorize us to obtain a consumer report and/or a investigative report about you for employment purposes and authorize all corporations, former employers, credit agencies, educational institutions, law enforcement agencies, military services and persons to release all information they may have about you. This authorization shall be valid in original or copy form. Name: Current address: City: State: Zip: Telephone: Cell phone: Social Security: / / Date of Birth: / / Driver s Licence Number: State: Signature: Date: Excellence Innovation Responsiveness

4 9641 Old Gentilly Road New Orleans, La MEDICAL HISTORY QUESTIONNAIRE Check all medical conditions that apply to you the applicant. A. Cancer/Tumors B. Heart/Circulatory C. Mental Health / Neurological A1. Chemotherapy B1. Anemia* C1. ADD/hyperactivity* A2. Hodgkin's Disease B2. Aneurysm C2. Alzheimer's A3. Leukemia B3. Congestive Heart Failure C3. Cerebral Palsy A4. Lymphoma B4. Coronary Artery Disease C4. Cystic Fibrosis A5. Radiation Therapy B5. Hemophilia C5. Depression A6. Tumor/Mole/Cyst* B6. Hepatitus C6. Drug/Alcohol Abuse* A7. Melanoma B7. High Blood Pressure C7. Epilepsy/Seizure* A8. Other ( ) B8. High Cholesterol* C8. Mental Retardation B9. HIV/AIDS C9. Multiple Sclerosis D. Muscular/Skeletal B10. Irregular Heartbeat C10. Paralysis/Hemiplegia B11. Stroke/TIA C11. Parkinson's D1. Arthritis* B12. Other ( ) C12. Therapy* D2. Bone/Fracture/Disc C13. Other ( ) D3. Lupus E. Lung/Respiratory D4. Muscular Dystrophy F. Intestinal/Endocrine D5. Neck/Back E1. Asthma/Allergy* D6. Spinal Column E2. Bronchitis/Pneumonia F1. Crohn's Disease D7. Other ( ) E3. Emphysema F2. Chronic Pancreatitis E4. Sleep Apnea F3. Colon Disorder G. Glandular/Hormonal E5. Tuberculosis F4. Diabates* E6. Other ( ) F5. Gallbladder G1. Adrenal Gland F6. Hernia/Reflux/Ulcer G2. Pituatary H. Miscellaneous F7. IBS/Colitus* G3. Other ( ) F8. Other ( ) H1. Birth Defects I. Eyes, Ears, se, Throat H2. Burns J. Liver/Kidney H3. Endometriosis* I1. Chronic Ear Infections H4. Gaucher's Disease J1. Kidney Stones I2. Cleft lip/palate H5. Lou Gerhic's Disease J2. Bladder or Kidney* I3. Chronic Sinusitus H6. Infertility Treatment J3. Cirrhosis I4. Acoustic Neuroma H7. Organ Transplant J4. Neuorgenic Bladder I5. Glaucoma H8. Polio J5. Polycystic Kidney I6. Cataracts H9. Other ( ) J6. Prostate Disorder I7. Retinopathy J7. Renal Failure I8. Other ( ) J8. Other ( ) Please answer these questions. 1. Have you ever had a disease or disability arising from your occupation? 2. Have you ever received worker's compensation benefits for an injury that occurred at work? 3. Have you ever been rejected for employment, insurance, or military service because of health? 4. Have you ever had back trouble or injury to your back, head, or neck? 5. Do you have any restrictions or disabilities that would limit your physical activities? 6. What operations, accidents, broken bones, strains or serious illnesses have you had? Excellence Innovation Responsiveness

5 9641 Old Gentilly Road New Orleans, La REQUEST FOR INFORMATION FROM PREVIOUS EMPLOYER Federal Highway D.O.T Section Date: / / Attention: Human Resources To Whom it may concern; SS#: has applied for employment at Metro Disposal, Inc. for a position as a and states that he/she was employed by your company as a _ from to. We appreciate your time in completing, in confidence, the information requested below. The federal Motor Carrier Safety Regulations require us to verify the applicants past three (3) years of employment. You are hereby authorized to supply Metro Disposal, Inc. With all information regarding my services, character, conduct and drug and alcohol testing results while in your employ. You are released from any and all liability, which may result from furnishing such information. Witness:_ Applicant Signature: Employed by you from to as a. Reasons for leaving your company: Discharged Resigned Laid Off Military Other: Wage or salary at time of employment: $ per hour per day weekly Would you re-employ? DOT regulation 49C.F.R requires your company to provide information concerning the above named driver past drug and alcohol test results, including refusals to be tested: Has the applicant tested positive for a controlled substance in the last two (2) years: If employed as a driver, did this person drive: Straight Truck Tracker Trailer Tank Other If other specify type: Number of accidents: Preventable: Any injuries: Any fatalities: Name: Title: Signature: Date: Please mail to: Human Resouces, 9641 Old Gentilly Road, New Orleans, La or you may fax: Excellence Innovation Responsiveness

6 U.S. Departmen t of Ju stice Immigration and Naturalization Service OMB Employ ment Eligibility Verification Please read instructions carefully before completing this form. The instructions must be available during completion of this form. ANTI-DISCRIMINATION NOTICE. It is illegal to discriminate against work eligible individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because of a future expiration date may also constitute illegal discrimination. Section 1. Employee Information and Verification. To be completed and signed by employee at the time employment begins Print Name: Last First Middle Initial Maiden Name Address (Street Name and Number) Apt. # Date of Birth (month/day/year) City State Zip Code Social Security # I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form. I attes t, under penalt y of per jur y, that I am (check one of the follow ing): A citizen or national of the United States A Lawful Permanent Resident (Alien # A An alien authorized to work until.... / / (Alien # or Admission # Employee s Signatur e Date (month/day/year ) Preparer and/or Translator Certification. (To be completed and signed if Section 1 is prepared by a person other than the employee.) I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct. Preparer's/Translator s Signature Print Name Address (Street Name and Number, City, State, Zip Code) Date (month/day/year) Section 2. Employer Rev iew and Verification. To be completed and signed by employer. Examine one document from List A OR examine one document from List B and one from List C as listed on the reverse of this form and record the title, number and expiration date, if any, of the document(s) List A OR List B AN D List C Document title: Issuing authority: Document #: Expiration Date (if any): / / Document #: Expiration Date (if any): / / / / / / CERTIFICAT ION - I attest, under penalty of perjury, that I have examined the document(s) presented by the above-named employee, that the above-listed document(s) appear to be genuine and to relate to the employee named, that the employee began employment on (month/day/year) / / and that to the best of my knowledge the employee is eligible to work in the United States. (State employment agencies may omit the date the employee began employment). Signature of Employer or Authorized Representative Print Name Title Business or Organization Name Address (Street Name and Number, City, State, Zip Code) Date (month/day/year) Section 3. UPDATING AND REVERIFICA T ION. To be completed and signed by employer A. New Name (if applicable) B. Date of rehire (month/day/year) (if applicable) C. If employee s previous grant of work authorization has expired, provide the information below for the document that establishes current employment eligibility. Document Title: Document #: Expiration Date (if any): / / I attest, under penalty of perjur y, that to the best of my knowledge, thi s employee is eligible to wor k in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative Date (month/day/year) * Form I-9 (Rev ) N * BCIS Changes Added by CSUDH Pending Issuance of Revised Form