PERSONAL DATA
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The Age Discrimination in Employment Act of 1967, as Amended, prohibits employment discrimination on the basis of age with respect to individuals who are age 40 and older.
If hired can you furnish proof that you are over the age of 18?
Yes
No
Have you ever applied for a job with this company?
Yes
No
Were you ever employed by this company?
Yes
No
If yes, then please fill out the following:
Dates Employed:
From:
To:
Job Title:
Location:
Supervisor:
Have you ever been convicted of a crime (other than a minor traffic violation)?
Yes
No
If yes, please explain:
The existence of a criminal record does not constitute an automatic bar to employment but will only be considered in relation to the specific requirements of the job for which you are applying.
Do you operate a business, or have other employment that will continue if employed by this company?
Yes
No
If so, state full particulars below.
What interested you in employment with us?
If an offer of employment is made, are you willing to undergo a physical examination at our expense by our physician to determine if you are physically able to perform the essential functions of the job for which you have applied (with or without a reasonable accommodation)?
Yes
No
If no, please explain:
EDUCATION
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Important - Please Read Before Submitting
I understand that the misrepresentation or ommission of facts in this application is just cause for termination. I am also aware that as part of normal procedures for processing applications for employment, a routine inquiry may be made concerning my character, general reputation, personal characteristics and mode of living. I understand that in compliance with public law 91-508, and upon my written request, additional information regarding the nature and scope of the responses to these inquiries, if made, will be provided to me.
(Disclaimer:
by submitting this application, you signify your agreement with the
terms of the application)