Curt G. Joa, Inc. – Application for Employment

Application for Employment

Instructions

If you need help to fill out this application form or for any phase of the employment process, please notify the human resources department and every effort will be made to accommodate your needs in a reasonable amount of time.

Please thoroughly read all statements contained in this Application form.
Complete all portions of this form completely and accurately.
Required fields are marked with a * character.
Incomplete applications will not be processed.

Applicant Note

This application form is intended for use in evaluating your qualifications for employment. This is not an employment contract. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment, terminating employment. This application applies only to the position specified. It is considered inactive after 90 days. If at any time after this point you wish to be considered for employment with this company, another application will have to be completed.

EEO Statement

We are an Equal Employment Opportunity employer, and do not discriminate in our hiring or employment practices. All qualified applicants will receive consideration without regard to race, color, creed, religion, national origin, age, disability, sex, or any other characteristic protected by State or Federal law.

Applicant Information

*Position Applied For

*First Name

Middle Name

*Last Name

*E-Mail Address

*Home Phone

Cell Phone

*Address

*City

*State

*Zip

Availability

*Are you legally authorized to work in the United States?
Yes No

*Are you under the age of 18?
Yes No

If yes, can you provide proof of eligibility to work?
Yes No

*On what date can you start?

*What job category would you prefer?
Full Time Part Time Temporary On-Call/Casual

*For what schedules would you be available?
Weekdays Weekends Days Evenings Overtime All Shifts Other

Education

*Please select the highest grade completed.

Name of High School

City

State

Degree
Earned

Name of College

City

State

Degree
Earned

Name of Other School

City

State

Degree
Earned

Background

*Have you ever been convicted of a crime (other than a moving violation) or served time? If so, please describe below. (Conviction of a crime does not automatically disqualify you from employment.)
Yes No

	Incident / Charge	City	State
1.

2.

Job-Related Skills

*Have you received a job description or had the requirements of the job explained to you?
Yes No

*Do you understand these requirements?
Yes No

*Can you perform the requirements of this job with or without reasonable accommodation?
Yes No

If the job requires you to drive, do you have the appropriate valid driver's license?
Yes No

License Number

Type

State of Issue

Have you had any moving violations?
Yes No

If "Yes" please describe

Please list any other skills, licenses or certifications that may be job-related or that you feel would be of value to this job or our organization.

Employment History

Your application may not be considered unless every question is answered. Since we may contact previous employers, correct telephone numbers are essential.

Most Recent Employer

Are you currently working for this employer?
Yes No

If yes, may we contact your current employer?
Yes No

Company Name

City

State

Phone Number

Start Month / Year

End Month / Year

Supervisor's Name

Phone Number

Job Title

Pay Rate

Hourly Annual

Job Duties

Reasons for Leaving

Second Most Recent Employer

Are you currently working for this employer?
Yes No

If yes, may we contact your current employer?
Yes No

Company Name

City

State

Phone Number

Start Month / Year

End Month / Year

Supervisor's Name

Phone Number

Job Title

Pay Rate

Hourly Annual

Job Duties

Reasons for Leaving

Third Most Recent Employer

Are you currently working for this employer?
Yes No

If yes, may we contact your current employer?
Yes No

Company Name

City

State

Phone Number

Start Month / Year

End Month / Year

Supervisor's Name

Phone Number

Job Title

Pay Rate

Hourly Annual

Job Duties

Reasons for Leaving

References

Include only individuals familiar with your work capabilities. Do not include relatives.

Reference #1 Name

Phone Number

Years Known
And Relationship

Reference #2 Name

Phone Number

Years Known
And Relationship

Reference #3 Name

Phone Number

Years Known
And Relationship

Resume

You may optionally upload a copy of your resume in addition to this application form. Files may be plain text, rich text, Microsoft Word or Adobe PDF format. Maximum file size is 500KB.

Certification

I certify the answers given by me to the foregoing questions and any statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions, or misrepresentations of facts regarding information called for in this application may result in rejection of my application, or discharge at any time during my employment. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. I understand that if I am hired, my employment shall be “at-will,” and that either the Company or I can choose to terminate the employment relationship for any reason, or no reason at all, with or without notice.

Authorization

I understand that background, drug, or medical testing may be conducted on me as part of the process to determine my fitness for employment, and hereby agree to submit to such testing. I authorize all persons, schools, companies, medical practitioners, current and/or former employers, and law enforcement authorities to release any information concerning my background or test results, and hereby release any said persons, schools, companies, medical practitioners, current and/or former employers, and law enforcement authorities from any liability for any damage whatsoever for issuing this information.

Your employment is contingent upon passing a drug screen.

Electronic Signature

*Applicant's Full Name

*Date

*Do you understand that by electronically submitting this application, it will be considered a legal document, just as if you had signed a paper copy of it?
Yes No

Affirmative Action Questions

The purpose of this section is to assist in monitoring Affirmative Action Programs and to aid in complying with any required governmental recordkeeping or reporting requirements. This information is not part of your employment application and will not be considered in the employment / selection process. The information requested is voluntary, and you will not be subject to any adverse treatment for choosing not to complete the questions.

What is your gender?
Male Female

What is your race / ethnic origin?

White	A person, not of Hispanic origin, having origins in any of the original peoples of Europe, North Africa, or the Middle East.
Black or African American	A person, not of Hispanic origin, having origins in any of the Black African racial groups.
Hispanic or Latino	A person of Mexican, Puerto Rican, Cuban, South or Central American or other Spanish culture, regardless of race.
Asian	A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent.
Native Hawaiian or Other Pacific Islander	A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
American Indian or Alaskan Native	A person having origins in any of the original peoples of North America and who maintains identifiable tribal affiliations through membership and participation or community recognition.
Two or more races

Do you have a mental or physical disability?

Yes No

Disability is defined as having a physical, sensory, or mental impairment (or condition) that materially (or significantly) limits one or more major life activities; having a record of such impairment; or being regarded as having such an impairment.

What is your Veteran / U.S. Military status (VETS 100A)?

(0) Non-Veteran
(1) Disabled Veteran	This term means (A) a veteran who is entitled to compensation under the laws administered by the Secretary of Veterans Affairs, or (B) a person who was discharged or released from active duty because of a service-connected disability.
(2) Armed Forces Service Medal Veterans	This term means any veteran who, while serving on active duty in the U.S. military participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order No. 12985.
(3) Recently Separated Veterans	This term means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military.
(4) Other Protected Veteran	This term means a veteran who served on active duty in the U.S. military during a war or in a campaign or expedition for which a campaign badge has been authorized, under the laws administered by the Department of Defense.