Nebraska Humane Society Employment Application

Transcription

1 GENERAL INFORMATION Last Name First Name Middle Initial Street Address Apt # City State Zip Home Phone (With area code) Work Phone (With area code) Other Phone (With area code) Have you previously used names other than what is provided above? Yes If yes, please specify: Are you at least 18 years of age? Yes Job applied for (Title): How did you learn of this vacancy? Salary Requirements: Are you available to work: Full-time Part-time Days Evenings Weekends A variable schedule Date Available: Have you ever been employed by the? Yes If yes, please list the job title, department, and dates. Are you now or have you ever been a volunteer for the Nebraska Humane Society? Yes If yes, please list the job title, department, and dates. Are you eligible for employment in the United States? Yes (Proof of eligibility will be required upon employment.) Have you ever been convicted of a felony or misdemeanor other than a minor traffic offense? Yes If yes, please explain. A record of conviction will not necessarily bar you from employment. EDUCATION High School Name City State Diploma/Equivalent? Yes College and/or Technical School Name Other Training or Degrees School Name City State Degree? Yes Major If degree not earned, years completed: City State Degree? Yes Major If degree not earned, years completed: PROFESSIONAL LICENSES (If hired, you will be required to provide proof of licensure.) Title. State Expiration Date Title. State Expiration Date Page 1 of 6

2 EMPLOYMENT HISTORY: (List employment for last 10 years beginning with current/last employer. Include U.S. military service. ) 1st. EMPLOYER NAME Address City State Zip Code Telephone Your Title Department ( ) Beginning Date Ending Date Final Salary Supervisor's Name & Title Summary of duties: Reason for leaving: May we contact your employer? Yes 2nd. EMPLOYER NAME Address City State Zip Code Telephone Your Title Department ( ) Beginning Date Ending Date Final Salary Supervisor's Name & Title Summary of duties: Reason for leaving: May we contact your employer? Yes 3rd. EMPLOYER NAME Address City State Zip Code Telephone Your Title Department ( ) Beginning Date Ending Date Final Salary Supervisor's Name & Title Summary of duties: Reason for leaving: May we contact your employer? Yes If you need more space, please attach a separate sheet of paper indicating the above information for each additional job. Have you ever been discharged or asked to resign from a job? Yes If yes, explain. SKILLS List software in which you are proficient: Second Languages, Including Sign Language. Language(s) Are you bilingual? Yes Fluency: Spoken: Excellent Good Fair Poor Written: Excellent Good Fair Poor Please list any other skills relevant to the job for which you are applying: DRIVING INFORMATION (Please complete if you are applying for a job that requires driving NHS vehicles.) Drivers License Number: Issuing State: Expiration Date: Do you have a good driving record? Yes If no, please explain: Page 2 of 6

3 Have you ever had any chargeable accidents or moving violations in the past 7 years?? Yes If yes, please explain: Is your knowledge of our city streets good?? Yes REFERENCES (Please list 3 business references other than those listed in the employment section.) Reference 1 Reference 2 Reference 3 Name Occupation Company Address Telephone Years Known Professional relationship to applicant. I hereby certify that the facts set forth in this employment application are true and complete to the best of my knowledge. I understand that misrepresentation or omission of facts, regardless of date of discovery, may be considered cause for termination or the withdrawal of an offer of employment. I further understand that any employment offered is for an indefinite duration, unless otherwise specified in writing, and is at-will, which means that either I or the may terminate my employment at any time with or without notice or with or without cause. I understand that neither the policies, rules, regulations of employment, application for employment, nor anything said during the interview process shall be deemed to constitute the terms of any implied employment contract. I authorize investigation and verification of all statements contained in this application for employment. I further authorize the Nebraska Humane Society to contact and/or interview any additional individuals, institutions and employers the becomes aware of during its investigation. Signature of Applicant: Date: My Initials provided in the box at left AND date entered on the line above serve as my electronic signature. Thank you for your interest in the. In order to have your application processed, you must thoroughly answer all questions on the application form. Applications filled out incompletely will not be considered. While we encourage you to attach a resume, please note that a resume will not substitute for completing any portion of this application. All information will be treated confidentially. The use of this form does not necessarily indicate that positions are open nor does it constitute an offer of employment or a contract of employment. The is an Equal Opportunity Employer and we consider applicants for all positions without regard to race, color, religion, sex, age, national origin, disabled or veteran status, or other legally protected status. Page 3 of 6

4 Applicant Consent to Drug Test/Back Screen To the Applicant: As part of its program to provide a safe and healthy work environment, the Nebraska Humane Society may ask you to take a drug test for a position in which you have received a conditional offer of employment. If the test is confirmed as positive, the results will be considered in any employment decision and will result in a rejection of an applicant for employment. In addition to a drug test, some positions require a post offer, pre employment back screen. If back screen testing results show that an applicant is unable to perform the essential functions of the position, with or without reasonable accommodations, the applicant will be denied employment. The expects you to sign this consent form. If you refuse to sign the consent form or fail to take the drug test or back screen, you will be denied employment. Consent I,, have read the foregoing statement and understand that the employment screening process may include a urine or other test which may disclose usage of drugs or which may reveal substance abuse or chemical dependency. I also understand that the employment screening process may include a physical and back screen for some positions. I hereby consent to such test(s) and to the disclosure of the results of the test(s) to the Nebraska Humane Society for its use and internal communication. I release and discharge the Nebraska Humane Society and any laboratory or physicians clinic which performs analysis form any claim or liability arising out of such test(s) including, without limitation, the testing procedures, the analysis or the disclosure of its results. I further consent, if hired, that my employment is subject to the policies and rules, as amended from time to time. Printed Name Signature Date Page 4 of 6

5 AUTHORIZATION TO PROCURE CONSUMER REPORTS AND/OR OTHER BACKGROUND INFORMATION I understand that the company or a third-party, consumer reporting agency acting on its behalf may conduct an investigation to obtain information about my background including, but not limited to: information about my personal character, previous employment, general reputation, educational background, credit history, driving record, and/or criminal history. I authorize all persons, corporation; credit agencies; education institutions; law enforcement agencies; city, state, country, and federal courts; and military services to release any such information about my background. Moreover, I authorize any person or entity conducting the investigation or compiling and/or processing such information to furnish the company, and/or any third party acting on the company s behalf, with such information. I release anyone providing such background information and the company from any and all liability and damages whatsoever in connection with collecting, furnishing, obtaining, or using such information. I further understand that the company will provide me with written notice if any adverse employment action is to be taken based in whole or in part on information contained in a consumer report within the meaning of the FCRA. Applicant s signature Applicant s Printed Name Date Page 5 of 6

6 Invitation to Applicants to Self-Identify The is tracking information to better understand the demographics of those applying. PLEASE NOTE: You are not required to complete any part of this form. The decision not to complete this form will not affect any opportunity for employment or any benefits with the company. Any information you provide in this survey will be kept confidential and will not be used in any way that may adversely affect your employment with this company. Name: Date: Position you are applying for: How were you referred to the company? GENDER: (Please check one): Male Female RACE/ETHNICITY: (Please check one of the descriptions below corresponding to the ethnic group with which you identify.) White (t Hispanic or Latino) A person having origins in any of the original peoples of Europe, the Middle East or rth Africa. Black or African American (t Hispanic or Latino) A person having origins in any of the black racial groups of Africa. Hispanic or Latino A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. Asian (t Hispanic or Latino) A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam. American Indian or Alaska Native (t Hispanic or Latino) A person having origins in any of the original peoples of rth and South America (including Central America) and who maintain tribal affiliation or community attachment. Native Hawaiian or Other Pacific Islander (t Hispanic or Latino) A person having origins in any of the peoples of Hawaii, Guam, Samoa or other Pacific Islands. Two or More Races (t Hispanic or Latino) All persons who identify with more than one of the above five races. Page 6 of 6