©2016 ComplyRight, Inc. A2179_FL Applicant Statement I certify that all information I have provided in order to apply for and secure work with this employer is true, complete, and correct. I expressly authorize, without reservation, the employer, its representatives, employees, or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities, and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resumé, or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees, or representatives, for seeking, gathering, and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations, or organizations for furnishing such information about me. I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state, or federal law. I understand that this application remains current for only 60 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application. If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer’s president. I understand that if I am hired, my employment will be subject to a probationary period, which ordinarily will not exceed 90 days from the date I am hired. If I am discharged at any time during the probationary period for unsatisfactory performance, I understand that this employer will not be charged for any unemployment benefits that may be paid to me for work I performed during the probationary period. I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard. I understand that reasonable safeguards will be taken to protect all personal information provided or obtained in conjunction with this application for employment. My personal information may be shared with the employer’s affiliate(s) and third parties engaged by the employer to perform services for the employer. Any personal information shared with an affiliate or third party is to be used solely to perform the services requested by the employer. This Company does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding an applicant from consideration for employment on the basis of his or her race, color, religion, sex (including pregnancy), national origin, age, handicap, disability, marital status, sickle cell trait, genetic information, or any other protected status under applicable federal, state, or local law. I understand that any information provided by me that is found to be false, incomplete, or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer’s service, whenever it is discovered. DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT. I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement. Signature of Applicant________________________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date _______________ / / Page 4 This product is designed to provide accurate and authoritative information. However, it is not a substitute for legal advice and does not provide legal opinions on any specific facts or services. The information is provided with the understanding that any person or entity involved in creating, producing or distributing this product is not liable for any damages arising out of the use or inability to use this product. You are urged to consult an attorney concerning your particular situation and any specific questions or concerns you may have. Important note: This is approved for use by the purchaser only. This form may not be shared publicly or with third parties. Related Information When answering these questions, please exclude any information that would reveal race, color, religion, sex (including pregnancy), national origin, age, handicap, disability, marital status, sickle cell trait, genetic information, or other similarly protected status. To what job-related organizations (professional, trade, etc.) do you belong? ________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ List special accomplishments, publications, awards, etc. _______________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ List any relevant volunteer work. _________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Is there any other job-related information you want us to know about you? ________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Please Print Application for Employment Florida If necessary, best time to call you is .................... ______________ ■ Home ■ Cellular/Other May we contact you at work?....................................... ■ Yes ■ No If yes, work number and best time to call: ________________________________ ______________ If you are under 18 and it is required, can you furnish a work permit?.................... N/A ■ Yes ■ No If no, please explain:________________________________ Have you submitted an application here before? ...... ■ Yes ■ No If yes, give date(s) and position(s):_____________________ ________________________________________________ Have you ever been employed here before?............... ■ Yes ■ No If yes, give dates: From ____________ To______________ Is this application a request for reemployment following an extended military leave of absence from this company?............................................... ■ Yes No If yes, additional information may be requested. Are you lawfully authorized to work in the United States?...................................................... ■ Yes No Date available for work......................................... ______________ What is your desired salary range or hourly rate of pay? $ _______________________ Per _________________ Type of employment desired: Full-Time Part-Time ■ Educational Co-Op Seasonal Temporary Will you relocate if job requires it? ............................. Yes No Will you travel if job requires it? .................................. Yes No If they have been explained to you, are you able to meet the attendance requirements of the position?... ■ N/A Yes No Will you work overtime if required?........................... ■ Yes ■ No If no, please explain:________________________________ Are you able to perform the “essential functions” of the job for which you are applying (with or without reasonable accommodation)? This question is not designed to elicit information about an applicant's disability. Please do not provide information about the existence of a disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stage to the extent permitted by law. ■ Yes ■ No ■ Need more information about the job’s “essential functions” to respond Driver’s license number required if driving may be required in the job for which you are applying: ____________________________________ State __________ Have you ever been bonded? ....................................... ■ Yes ■ No Have you ever pleaded “guilty” or “no contest” to or been convicted of a crime? NOTE: Answering “yes” to this question or the next does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account. You are not obligated to disclose sealed or expunged records of conviction or arrest................................. ■ Yes ■ No If yes, please provide date(s) and details: ________________________________________________ Have you ever been a defendant in a civil action for an intentional tort (e.g., a civil charge for assault, battery,intentional infliction of emotional distress, false imprisonment, wrongful death, etc.)? .....................................................................■ Yes ■ No If yes, please provide nature of the tort and disposition of the matter (how it was resolved). ________________________________________________ Have you entered into an agreement with any former employer or other party (such as a noncompetition agreement) that might, in any way, restrict your ability to work for our company?.......■ Yes ■ No If yes, please explain: _______________________________ ________________________________________________ : AM PM : AM PM ( ) / / / / / / AN EQUAL OPPORTUNITY EMPLOYER Page 1 Equal access to programs, services and employment opportunities is available to all persons without regard to race, color, religion, sex (including pregnancy), national origin, age, handicap, disability, marital status, sickle cell trait, genetic information, or any other basis protected by federal, state, and/or local law. In accordance with the Americans with Disabilities Act and/or applicable state and local laws, applicants requiring reasonable accommodations for the application and/or interview process should notify the Human Resources Department. Examples of reasonable accommodations include making a change to the application process; providing written materials in an alternate format such as braille, large print, or audio recording; using a sign language interpreter; using specialized equipment; or modifying testing conditions. Name __________________________________________________________________ Applicant ID # _____________________ Address __________________________________________________________________________________________________ Telephone # _________________ Cellular/Other Phone # ________________ E-mail Address ____________________________ Position(s) applied for _____________________________________________________ Date of application __________________ Referral Source (e.g., Walk-in, Job Posting, Company’s Website, etc.) _________________________________________________________ Last First Middle Street City State ZIP Code ( ) / / ( ) If necessary, best time to call you is .................... ______________ ■ Home ■ Cellular/Other May we contact you at work?....................................... ■ Yes ■ No If yes, work number and best time to call: ________________________________ ______________ If you are under 18 and it is required, can you furnish a work permit?.................... ■ N/A ■ Yes ■ No If no, please explain: _______________________________ Have you submitted an application here before? ...... ■ Yes ■ No If yes, give date(s) and position(s): ____________________ ________________________________________________ Have you ever been employed here before?............... ■ Yes ■ No If yes, give dates: From ____________ To______________ Is this application a request for reemployment following an extended military leave of absence from this company?........... ■ Yes ■ No If yes, additional information may be requested. Are you lawfully authorized to work in the United States?...................................................... ■ Yes ■ No Date available for work......................................... ______________ What is your desired salary range or hourly rate of pay? $ _______________________ Per _________________ Type of employment desired: ■ Full-Time ■ Part-Time ■ Educational Co-Op ■ Seasonal ■ Temporary Will you relocate if job requires it? ■ Yes ■ No ( ) : AM PM / / / / / / : AM PM Will you travel if job requires it? ..................................■ Yes ■ No If they have been explained to you, are you able to meet the attendance requirements of the position?... ■ N/A ■ Yes ■ No Will you work overtime if required?........................... Yes No If no, please explain: _______________________________ ________________________________________________ Are you able to perform the “essential functions” of the job for which you are applying (with or without reasonable accommodation)? This question is not designed to elicit information about an applicant's disability. Please do not provide information about the existence of a disability, particular accommodation or whether accommodation is necessary. These issues may be addressed at a later stage to the extent permitted by law. Yes No Need more information about the job’s “essential functions” to respond Driver’s license number required if driving may be required in the job for which you are applying: ____________________________________ State __________ Have you ever been bonded? ....................................... Yes No Have you entered into an agreement with any former employer or other party (such as a noncompetition agreement) that might, in any way, restrict your ability to work for our company?........ Yes No If yes, please explain: _______________________________ ________________________________________________ ________________________________________________ NOTE TO RHODE ISLAND APPLICANTS: This company is subject to the state’s workers’ compensation laws (Chapter 29-38) unless otherwise noted below (employer to list applicable exemptions): ____________________________________________________ ____________________________________________________ ____________________________________________________ AN EQUAL OPPORTUNITY EMPLOYER Page 1 Equal access to programs, services and employment opportunities is available to all persons without regard to sex (including pregnancy), race, color, religion, national origin, citizenship, age, disability, genetic information, or any other basis protected by federal, state, and/or local law. In accordance with the Americans with Disabilities Act and/or applicable state and local laws, applicants requiring reasonable accommodations for the application and/or interview process should notify the Human Resources Department. Examples of reasonable accommodations include making a change to the application process; providing written materials in an alternate format such as braille, large print or audio recording; using a sign language interpreter; using specialized equipment; or modifying testing conditions. Name __________________________________________________________________ Applicant ID # _____________________ Address __________________________________________________________________________________________________ Telephone # _________________ Cellular/Other Phone # ________________ E-mail Address ____________________________ Position(s) applied for _____________________________________________________ Date of application __________________ Referral Source (e.g., Walk-in, Job Posting, Company’s Website, etc.) _________________________________________________________ Last First Middle Street City State ZIP Code ( ) / / ( ) Please Print Application for Employment Name_______________________________________________________________________________________________________ Address _____________________________________________________________________________________________________ Email address _________________________________________________________________ Phone ________________________ Position applied for _____________________________________________________________ Shift preferred ■ 1 ■ 2 ■ 3 ■ Any Special training or skills (languages, machine operation, etc.) that would benefit you in the job for which you are applying: ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ Would you accept full-time work? Yes No Would you accept part-time work? Yes No On what date would you be available for work? ________________________________ Have you ever been employed here? Yes No If yes, dates: _________________________________________________________ Are you lawfully authorized to work in the United States? Yes No If you are under 18 years old, can you furnish a work permit if required? N/A Yes No Are you able to perform the essential functions of the job for which you are applying (with or without reasonable accommodation)? This question is not designed to elicit information about an applicant’s disability. Please do not provide information about the existence of a disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stage to the extent permitted by law. Yes No Need more information about the job’s essential functions to respond. ( ) Last First Middle Street City State ZIP Code Notice to Rhode Island applicants: This Company is subject to the state’s workers’ compensation laws (Chapters 29-38) unless otherwise noted below: _____________________________________________________________________________________________________________________________________ (Employer to list applicable exemptions) Please Print Application for Employment Equal access to programs, services and employment opportunities is available to all persons without regard to sex (including pregnancy), race, color, religion, national origin, citizenship, age, disability, genetic information, or any other basis protected by federal, state, and/or local law. In accordance with the Americans with Disabilities Act and/or applicable state and local laws, applicants requiring reasonable accommodations for the application and/or interview process should notify the Human Resources Department. Examples of reasonable accommodations include making a change to the application process; providing written materials in an alternate format such as braille, large print, or audio recording; using a sign language interpreter; using specialized equipment; or modifying testing conditions. Starting with your most recent school attended, provide the following information. Educational Background School (include City and State) # of Years Completed Completed GPA Class Rank Major/Minor ■ Diploma ■ GED ■ Degree ______________________ ■ Certification __________________ ■ Other________________________ ■ Diploma ■ GED ■ Degree ______________________ ■ Certification __________________ ■ Other________________________ ■ Diploma ■ GED ■ Degree ______________________ ■ Certification __________________ ■ Other________________________ ■ Diploma ■ GED ■ Degree ______________________ ■ Certification __________________ ■ Other________________________ 5 Hiring Tools State-Compliant Job Applications Attorney-developed State-Compliant Job Applications support employers in their hiring process by capturing essential details and complying with the latest federal and state requirements. • Contains all mandatory disclosures and omissions required by state and federal law • Includes equal employment opportunity, reasonable accommodations and confidentiality statements • Compliant with state laws including, but not limited to, Juvenile Reporting, Previous Salary History, and Ban-the-Box laws Description Item # State Compliant Job Application, 50 Pack A2179XX* *Replace XX with your state abbreviation (e.g. A2179FL) Essential Workplace Policies Address workplace issues with written policies on everything from overtime to discrimination and harassment. Provides attorney-approved, pre-written policies to protect your workplace and avoid unexpected legal issues or lawsuits. • More than 50 current, legally compliant employee policies • Includes up-to-date, most trending workplace policies • Easy electronic format to email to your employees or print unlimited copies Description Item # Essential Workplace Policies A3016CD 50-State Compliant Application for Employment (Short and Long Form) Ideal for most entry-level, non-exempt positions. The two-sided form includes clear, direct questions to keep matters brief, while still allowing ample room for skills, employment history and education information. • Includes equal employment opportunity, reasonable accommodations and confidentiality statements • Includes plain-language disclosures to minimize exposure to discrimination charges Description Item # 50-State Compliant Job Application (Short Form), 50 Pack AR0374 50-State Compliant Job Application (Long Form), 50 Pack A0019 ComplyRight™ Hiring Essentials This CD-ROM is the perfect solution for all your hiring needs. It contains eight important forms and tip sheets chock-full of best practices, practical pointers and compliance information. • Print as many forms as you need, when you need them • Includes ComplyRight™ tips for optimal use Description Item # CD-ROM A2271 Size of all forms and tip sheets: 8.5" x 11" Adobe Acrobat 5.0 or later required for downloadable forms. Provides these printable forms: • Job Application • Interview Evaluation • Background Check • Form I-9 • Form W-4 • Employee Information Sheet • Direct Deposit