EMPLOYMET APPLICATIO (PLEASE PRIT AD COMPLETELY ASWER ALL QUESTIOS) Our company ( Company ) fully subscribes to the principles of Equal Employment Opportunity. It is our policy to provide employment, compensation, and other benefits related to employment based on qualifications, without regard to race, color, religion, national origin, age, sex, veteran status, genetic information, disability, or any other basis prohibited by federal, state or local law. In accordance with requirements of the Americans with Disabilities Act and applicable state laws, it is our policy to provide reasonable accommodation upon request during the application process to eligible applicants in order that they may be given a full and fair opportunity to be considered for employment. As an Equal Opportunity Employer, we intend to comply fully with applicable federal and State employment laws and the information requested on this application will only be used for purposes consistent with those laws. To the extent required by applicable law, The Company maintains a smoke- free workplace. Applicants for positions in Rhode Island please note that the Company and ADP TotalSource, our Professional Employer Organization are subject to Chapters 29-38 of Title 28 of the General Laws of Rhode Island and are therefore covered by the state's workers compensation law. COMPAY: POSITIO APPLIED FOR: DATE: PERSOAL DATA Salary expectations: ame: Last Middle First Street Address: City: State: Zip Code: Telephone: If you are under 18 years of age, please specify your age: for child labor law purposes). ( This information will be used only Are there any days, shifts or hours you will not work? Yes o If yes, please explain: Are you available for out of town work? Yes o Will you work overtime, if required? Yes o When will you be able to start work? Page 1 of 6
Have you ever been found at fault in a civil action for an intentional tort (intentional commission of a wrongful act)? Yes o ote: Answering yes does not automatically exclude you from further consideration for the position. If yes, include nature of the intentional tort and the disposition of the action: How did you learn of the Company? If referral, who were you referred by? Have you ever applied or worked for ADP TotalSource or the Company before? Yes o If yes, provide dates: Are you legally authorized to work in the United States? Yes o Will you now or in the future require sponsorship for employment visa status (e.g.,h-1b visa status)? Yes o ote: The Federal Immigration and Reform and Control Act of 1986 requires that a DHS Employment Eligibility Verification Form I-9 be completed for every new hire and that within 3 business days of beginning work every new hire must present to the employer documentation establishing his/her identity and authorization to work. This federal requirement must be satisfied as a condition of employment. DRIVIG RECORD (Answer only if driving is a requirement of the job for which you are applying). Do you have a valid driver s license? Yes o State: License o: Have you had any tickets? Yes o If yes, please explain: Page 2 of 6
EDUCATIO Describe any educational degrees, skills, training or experience you believe are relevant to the job applied for: ame, City and State of Educational Institution Graduated Yes o If no, Degree Credits Earned Type of Degree Received or Expected Major Minor Grade Point/ Overall GPA High School College or University Technical/GED Licenses/ Certification/Other EMPLOYMET HISTORY: Please complete for all full-time or part-time employment beginning with most recent employer. You may include as part of your employment history any verified work performed on a volunteer basis. All applicants should start with their most recent job, include active military assignments and voluntary employment and provide ten (10) years of history. (A separate sheet may be attached.) You must explain any gaps in your employment history. Company ame: Telephone: Address: ame of Supervisor: May we contact: Yes o Dates Employed: From: To: Rate of Pay: Start: Last: State job titles and describe job duties: Reason for leaving: Company ame: Telephone: Address: ame of Supervisor: May we contact: Yes o Dates Employed: From: To: Rate of Pay: Start: Last: State job titles and describe job duties: Reason for leaving: Page 3 of 6
Company ame: Telephone: Address: ame of Supervisor: May we contact: Yes o Dates Employed: From: To: Rate of Pay: Start: Last: State job titles and describe job duties: Reason for leaving: Company ame: Telephone: Address: ame of Supervisor: May we contact: Yes o Dates Employed: From: To: Rate of Pay: Start: Last: State job titles and describe job duties: Reason for leaving: Please explain any gaps in your employment history: Have you ever been discharged or forced to resign? Yes o If yes, explain: Did you receive any discipline in your last 12 months of active employment with your previous employer? Yes o If yes, please explain: Were you given a performance evaluation within the last 12 months of active employment? Yes o If yes, what was the range of scores used and what was your score? Have you signed any non-competition or non-solicitation agreement with any other employer that might restrict you from working for the Company (you may be required to furnish a copy of the agreement)? Yes o If yes, please explain: Page 4 of 6
REFERECES (Please list three persons not related to you who know your qualifications.) AME ADDRESS PHOE RELATIOSHIP MILITARY (Complete only if you served in the military.) Branch of Service: umber of Years /Months of Service: Rank at Discharge; Date of Discharge: Reason for Leaving: Describe any military skills, training or experience you believe are relevant to the job you applied for: LIE DETECTOR TESTS Massachusetts Applicants ote: It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability. Maryland Applicants ote: An employer may not require or demand, as a condition or prospective employment or continued employment, an individual submit to or take a lie detector or similar test. An employer who violates this law is guilty of a misdemeanor and subject to a fine not exceeding $100. I have read and acknowledge this notice: Applicant s Signature: Page 5 of 6
APPLICAT S ACKOWLEDGMET I certify that the answers given herein (including but not limited to the Criminal and Additional Driver Record Information Supplement and Commercial Motor Vehicle Driver Supplement if applicable) are true and complete to the best of my knowledge. I understand that any misrepresentations, omissions of facts or incomplete answers in any application document may disqualify me from further consideration for employment. I further understand that, if employed, any misrepresentations or omissions of facts in any application document may be cause for my dismissal at any time without prior notice. I consent to and authorize the Company and ADP TotalSource to contact my former employers, references, and any and all other persons and organizations for information bearing upon my qualifications for employment. I further authorize the listed employers, schools and personal references to give the Company or ADP TotalSource (without further notice to me) any and all information about my previous employment and education, along with any other pertinent information they may have and hereby waive any actions which I may have against either party(ies) for providing a good faith reference. I EXPRESSLY AGREE AD UDERSTAD THAT, IF EMPLOYED, MY EMPLOYMET IS OT FOR A SPECIFIC TERM, IS BASED O MUTUAL COSET AD MAY BE TERMIATED BY ME OR THE COMPAY OR ADP TOTALSOURCE WITH OR WITHOUT OTICE OR CAUSE AT AY TIME. I FURTHER UDERSTAD THAT O ORAL PROMISE, EMPLOYER POLICY, CUSTOM, BUSIESS PRACTICE OR OTHER PROCEDURE (ICLUDIG THE BASIC EMPLOYMET POLICIES, PERSOEL HADBOOK OR AY PERSOEL MAUALS) COSTITUTES A EMPLOYMET COTRACT OR MODIFICATIO OF THE AT-WILL EMPLOYMET RELATIOSHIP BETWEE ME AD THE COMPAY OR ADP TOTALSOURCE. I ALSO UDERSTAD THAT THIS ASPECT OF MY EMPLOYMET WITH THE COMPAY MAY OLY BE ALTERED WITH A WRITTE AUTHORIZATIO SIGED BY THE CHIEF EXECUTIVE OFFICER OF THE COMPAY, AD THAT MY AT-WILL STATUS WITH ADP TOTALSOURCE MAY OT BE ALTERED. I understand that applicants for certain positions may be required to qualify for employment based on additional employment criteria. For example, I may be required to take job-related tests; take a driver s examination; submit to a background investigation or take a pre-employment drug test. If I am offered employment or start work before any required test is completed, my employment is contingent on a satisfactory result on all required tests. I authorize the Company and ADP TotalSource to release the results of background checks (if any) and my pre-employment drug/alcohol test (if any), any information on this application and any relevant information about me to each other and to other ADP TotalSource clients for whom I have applied for employment, and release the Company, ADP TotalSource and its clients from any and all claims related to the lawful release of this information. I further authorize the release of any background check results and of any drug/alcohol test to any state or federal authority requesting such information and in response to a valid subpoena or other legal document. CALIFORIA APPLICATS OLY: I understand the Company or ADP TotalSource may obtain, without using the services of a third party investigative consumer reporting agency, public records pertaining to my character, general reputation, personal characteristics or mode of living during its evaluation of my application for employment and, if employed, during my employment. By checking the following box, I waive my right to receive copies of public records obtained by the Company or ADP TotalSource. Signature: Date: Page 6 of 6
Consent to Conduct Background Investigation Worksite Employer: First ame: Company Code: Division Code: Middle ame: Required Optional Last ame: Other names you have used: - - - - Date of Birth: Social Security umber: Gender: Driver s License umber: State Issued: Race: List below all addresses for last SEVE years starting with most current (attach additional page if necessary): Street Address City State Zip County Dates 1 2 3 4 5 6 I understand that, as a condition of my employment, ADP TotalSource, its parent and subsidiary com pa nies, af fil i ates, and Clients, including my worksite employer (collectively TotalSource ), will use the services of a con sum er re port ing agen cy to verify the information I have provided on my employment ap pli ca tion, and may, during my employment if hired, use the services of a consumer reporting agency for purposes of making an employment decision. I understand that my successful completion of a background investigation is a material term and condition of employment and if I start work before the investigation is completed, my employment will be contingent on the results. I understand the investigation may include obtaining information covering up to (1) the last seven (7) years regarding my work habits, education, general reputation, personal char ac ter is tics, credit history, driving records, mode of living, government-issued licenses, judgment liens, criminal background, references, character, past employment, and (2) the last ten years regarding bankruptcies. I understand such information may be obtained by direct or indirect contact from former em ploy ers, schools, financial institutions, landlords and public agencies and through personal interviews with my neighbors, friends and associates, acquaintances or other persons who may have such knowledge. The information requested is required by law enforcement agencies and other entities for positive identification purposes and will not be used for any other purpose. By checking this box, I authorize you to contact my current employer. In the event personal interviews are conducted, I understand that I have the right to receive notice about the nature and scope of any investigative consumer report within five days after TotalSource receives my request or five days after the investigative consumer report was requested, whichever is later, unless a shorter time is required by state law. By checking this box I indicate that I wish to receive further disclosure about the nature and scope of any TotalSource request for an investigative consumer report. I also understand that before I am denied employment based on information obtained in the report, I will be provided a copy of the report and a description in writing of my rights under the Fair Credit Reporting Act. I understand if I disagree with the accuracy of any information in the report, I must notify TotalSource within five business days of my receipt of the report. If I notify TotalSource within five days of the receipt of the report that I am challenging in for ma tion in the report, TotalSource will not make a final decision on my employment status until after I have had a reasonable opportunity to address the discrepancy. I hereby consent to this investigation and authorize TotalSource to procure a report on my background from a consumer reporting agency. I authorize ADP TotalSource and its clients to release the results of background checks to each other and to other ADP TotalSource clients for whom I have applied for employment, and release ADP TotalSource and its clients from any and all claims related to the lawful release of this information. I release TotalSource and any and all persons or entities providing information or reports about me from any liability arising out of the requests or release of information. This report will be processed by: ADP Screening and Selection Services - 301 Remington Street - Fort Collins, Colorado 80524 / 800-367-5933. California applicants only: The nature and scope of the investigation sought is as follows:. I have the right to request a copy of my consumer report from the consumer reporting agency by checking this box. The report will be sent directly to me by the agency to my most current address listed. I understand I have the right to inspect visually the files concerning me maintained by an investigative consumer credit reporting agency during normal business hours and upon reasonable 2009 ADP TotalSource, Inc. P1-103-0709
notice. The inspection can be done in person if I appear in person and furnish proper identification; I am entitled to a copy of the file for a fee not to exceed the actual costs of duplication. I am entitled to be accompanied by one person of my choosing, who shall furnish reasonable identification. The inspection can also be done via certified mail if I make a written request, with proper identification, for copies to be sent to a specified addressee. I can also request a summary of the information to be provided by telephone if I make a written request, with proper identification for telephone disclosure, and the toll charge, if any, for the telephone call is prepaid by or directly charged to me. I further understand that the investigative consumer credit reporting agency shall provide trained personnel to explain to me any of the information furnished to me; I shall receive from the investigative consumer reporting agency a written explanation of any coded information contained in files maintained on me. Proper identification as used in this paragraph means information generally deemed sufficient to identify a person, including documents such as a valid driver s license, social security account number, military identification card and credit cards. Massachusetts Applicants only: The specific nature and scope of the investigation involving personal interviews includes:. I also understand that before or in the event I am denied employment based, in whole or in part, on information obtained in the report, I will be provided a copy of the report and a description in writing of my applicable state rights. Minnesota applicants only: I have the right to request a copy of my consumer report from the consumer reporting agency by checking this box. The report will be sent directly to me by the agency to my most current address listed. I also have the right, upon my direct request to the consumer reporting agency, to obtain a complete an accurate disclosure of the nature and scope of the consumer report. The disclosure obtained from the consumer reporting agency must be in writing and mailed or delivered to me within five days after the request for the disclosure was received or the consumer report was requested, whichever is later. ew Jersey applicants only: The specific nature and scope of the investigation involving personal interviews includes:. Oklahoma applicants only: I have the right to request a copy of my consumer report from the consumer reporting agency by checking this box. The report will be sent directly to me by the agency to my most current address listed. Washington applicants only: I also understand that before or in the event I am denied employment based, in whole or in part, on information obtained in the report, I will be provided a copy of the report and a description in writing of my applicable state rights. Employee Signature Date For Worksite Employer Use Only Position offered: First Check Credit Motor Vehicle Driver s License#: State Issued: CrimLink State Criminal State: State: State: County Criminal County ame: State: Federal Criminal Employment Please include a copy of the application or resume for this information (Verify applicant consent above) Education Please include a copy of the application or resume for this information Government Registries Sex Offender Registry State(s): OIG/GSA Government Sanctions Registry Please return completed results via e-mail: Or by Secure Fax to # For Processing, please fax this form to the ADP TOTALSOURCE SHARED SERVICE CETER AT 866-580-3238 or e-mail to TOTALSOURCE_SSC@adp.com Phone: 866-400-6011, option 1 For ADP TotalSource Use Only Date Form Was Received: Processed By: Date: 2009 ADP TotalSource, Inc. P1-103-0709
DISC Instructions When completing the DISC Assessment questionnaire, please circle your responses with a pen. In order to complete this questionnaire, please do the following: 1. Study the four descriptive words in the first group of words while thinking about how you act and feel in your selected setting or focus. It is up to you to decide on the setting or focus, but it is highly recommended that you would choose WORK SETTIG for the purpose of this exercise. 2. Select only one word that MOST describes you, and use your pen to circle the choice. 3. Select only one word that LEAST describes you, and use your pen to circle the choice. 4. Use the same procedure to respond to the remaining groups of descriptive words. For example: Most Least Most Least Most Least Most Least Enthusiastic Poised Attractive Impulsive Daring Diplomatic Satisfied Observant Modest Impatient Introspective Stubborn Predictable Introverted Forceful Easy-going
DISC Response Page ame: Circle one MOST and one LEAST in each of the groups of words. Most Least Most Least Most Least Most Least Enthusiastic Poised Attractive Impulsive Daring Diplomatic Satisfied Observant Modest Impatient Introspective Stubborn Predictable Introverted Forceful Easy-going Cautious Tactful Logical Good Mixer Determined Convincing Good-natured Agreeable Magnetic Insistent Bold Loyal Charming Refined Vigorous Lenient Friendly Accurate Brave Inspiring Sociable Patient Captivating Contented Outspoken Calm Submissive Timid Self-reliant Soft-spoken Demanding Compliant Talkative Controlled Conventional Decisive Reserved Obliging Strong-willed Cheerful Willing Eager Thorough High-spirited Z Argumentative Systematic Cooperative Light-hearted Adventurous Insightful Stimulating Kind Aggressive Extroverted Jovial Precise Out-going Moderate Gentle Persuasive Humble Original Z Perceptive Independent Competitive Considerate Joyful Private Amiable Fearful Confident Sympathetic Impartial Assertive Direct Even-tempered Restless eighborly Appealing Careful Expressive Conscientious Dominant Responsive Fussy Obedient Firm Playful Well-disciplined Generous Animated Persistent Respectful Pioneering Optimistic Helpful