Click here for a printer friendly version
Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department.
 
Applicant Name
First MI Last
Date of application 02/06/2012
Position(s) applied for or type of work desired
Are you capable of performing the essential functions of the position for which you are applying, with or without reasonable accommodation?
Yes No
If no, please explain:

 
Address
 
City
State
ZipCode
Home Telephone Number
Alternate Telephone Number
Social Security Number
E-mail Address
Referral Source (How did you hear about us?)
List relatives currently employed by HR Concepts
Type of employment desired Full-Time Part-Time Temporary
Date you will be available to start work
Desired Salary Range
Do you have any objection to working overtime if necessary? Yes No
Have you ever been previously employed by our organization? Yes No
If yes, what position did you hold and for what time period?
Are you legally authorized to work in the United States? Yes No
If yes, are you only authorized to work for your current employer, or all employers? Current All
If you are under 18, can you furnish a work permit if it is required? Yes No
 
Before answering the following question, please see the information below if you are applying for a position in California, Colorado, Conneticut, Georgia, Louisiana, Maryland, New York or Virginia.
 
Have you ever been convicted, plead guilty, or plead no contest to a crime?
Yes No
   
If yes, please explain:

Colorado, Maryland, and Virginia: applicants need not provide information regarding sealed, erased, expunged, or impounded records.

California: applicants: in accordance with California Labor Code Sections 423.7 and 423.8, please do not disclose information regarding any misdemeanor convictions from marijuana-related offenses that are more than two years old or any other information regarding any pre trial or post-trial diversion programs in which you have participated.

Connecticut: applicants need not disclose the existence of any arrest, criminal charge or conviction if such records have been erased pursuant to § 46b-146, § 54-142a or § 54-760 of the Connecticut General Statues; criminal records subject to erasure under the above-referenced sections are records pertaining to a finding of delinquency or that a child was a member of a family with service needs, and adjunction as a youthful offender, a criminal charge that had been dismissed or nolled, a criminal charge for which the person has been found guilty or a conviction for which the person received an absolute pardon; and any person whose criminal records have been erased pursuant to the above-references sections shall be deemed to never have been arrested within the meaning of the Connecticut General Statues with respect to the proceedings which have been erased, and may swear to this under oath.

Georgia: applicants should not disclose any information pertaining to convictions protected under the first Offenders Act.

Louisiana: applicants should only provide information in connection with felonies.

New York: applicants should not provide information pertaining to: (i) convictions that have been sealed pursuant to Section 160.55 of the Criminal Procedure Law; or (ii) youthful offender adjudications.

Your answers to these questions will not necessarily be a bar to employment. This information will be used only for job-related purposes, and only to the extent permitted by law.

 
Driver's license number (if driving is an essential job duty)
State

 

Employment History
Please provide all employment information for your past three employers, starting with the most recent.
Employer 1
Employer
Phone
Position Held
City
State
Supervisor
Job Summary
Reason for Leaving
Dates Employed
To
Compensation (Starting)
$ Per
Compensation (Final)
$ Per
May we contact for reference?

 

Employer 2

Employer
Phone
Position Held
City
State
Supervisor
Job Summary
Reason for Leaving
Dates Employed
To
Compensation (Starting)
$ Per
Compensation (Final)
$ Per
May we contact for reference?

 

Employer 3

Employer
Phone
Position Held
City
State
Supervisor
Job Summary
Reason for Leaving
Dates Employed
To
Compensation (Starting)
$ Per
Compensation (Final)
$ Per
May we contact for reference?

 

Other Skills and Qualifications
Summarize any job-related training, skills, licenses, certificates, and/or other qualifications
Computer Skills (Check appropriate boxes. Include software titles and years of experience.)
  Software Years
Word Processing
Spreadsheet
Presentation
E-Mail
Internet
Other

 

Educational history
List school name and location, years completed, course of study, and any degrees earned

School City State

Number of
Years Completed

 Completed Major/Minor
Diploma Degree
Certification GED
Other  
Diploma Degree
Certification GED
Other  
Diploma Degree
Certification GED
Other  

 

References
 List 3 references' names, telephone numbers, and years known (do not include relatives)

Name Phone Years Known
   

Were you known under a different name? If yes, include prior name(s) and dates:
Applicant Statement

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

IMPORTANT

Maryland Applicants Only: Please review and accept the following:
I certify that I have read, fully understand and accept all terms of the foregoing Maryland Applicant Disclaimer.

IMPORTANT

California Applicants Only: Please consider the following:

I understand that I am not required to select this option, but I wish for the company to keep my contact information private.

This application will not be completed until you click the "Submit" button below