Employment Application "*" indicates required fields Step 1 of 9 11% THIS APPLICATION IS NOT AN EMPLOYMENT CONTRACT but merely is intended to evaluate suitability for employment. Should you need assistance with this application, please contact Lori Hall at (270) 362-8661. It is the policy of the Company to provide equal employment to all qualified persons without discrimination on the basis of sex, race, color, religion, age, marital status, national origin, citizenship, disability, veteran status, and any other legally protected status under state and federal law. We encourage women and minority to apply. It is also the policy of the Company to have the option of conducting preemployment screening before a job offer is made. If a job offer is made, employment may be contingent upon a successful completion of a medical examination, which may include providing body substance samples.PERSONAL INFORMATIONName* First Middle Last Email* Home Phone*Work Phone Please list below your current address and your two other most recent addresses:Current Address* Street Address City State / Province / Region ZIP / Postal Code You've Lived At Your Current Address Since (Mo/Yr)?* Previous Address* Street Address City State / Province / Region ZIP / Postal Code When Did You Live At This Address (Mo/Yr)? Previous Address* Street Address City State / Province / Region ZIP / Postal Code When Did You Live At This Address (Mo/Yr)? EDUCATIONHigh School Attended* City, County & State* Did You Earn a Diploma?* Yes No Undergraduate College Attended City, County & State Areas of Study Degree/Certificate/Diploma Graduate College Attended City, State Areas of Study Degree/Certificate/Diploma Trade, Business or Other School City, State Areas of Study Degree/Certificate/Diploma EMPLOYMENT INFORMATIONPosition Applied For* Date You Can Start Work* Month Day Year Desired Salary* Do You Prefer* Full-Time Part-Time Can You Work* Weekends Evenings Please answer all of the following questions. When necessary, please provide explanations and note question number in the box after question #8: 1) Are you at least 18 years of age and legally eligible for work in the United States?* Yes No 2) Will You Work Overtime When Necessary* Yes No 3) Have you received a description of the job or been made aware of the essential functions of the job you are applying for?* Yes No 4) Do you understand the job requirements? (If no, please explain below)* Yes No 5) Are you on layoff and subject to recall?* Yes No 6) Are you currently bound by a noncompetition or trade secret agreement? (If yes, please explain below)* Yes No 7) Have you ever been discharged or asked to resign from a job? (If yes, please explain below)* Yes No 8)Have you ever been involuntarily terminated from a job? (If yes, please explain below)* Yes No Please Provide Any Explanations Here (Note Question Number) EMPLOYMENT HISTORYMAY WE CONTACT YOUR PRESENT EMPLOYER?* Yes No Please list below your last four employers beginning with the most recent: Most Recent Employer* Phone*City* State* Zip Code* Position Held* Dates From/To* Pay Rate Upon Leaving* Supervisor* Duties* Reason for Leaving* Next Most Recent Employer PhoneCity State Zip Code Position Held Dates From/To Pay Rate Upon Leaving Supervisor Duties Reason for Leaving Next Most Recent Employer PhoneCity State Zip Code Position Held Dates From/To Pay Rate Upon Leaving Supervisor Duties Reason for Leaving Next Most Recent Employer PhoneCity State Zip Code Position Held Dates From/To Pay Rate Upon Leaving Supervisor Duties Reason for Leaving JOB-RELATED SKILLSPlease answer the following questions if the position you are applying for requires driving a motor vehicle: 1) Do You Have a Valid Driver's License? Yes No (If YES) Driver's License Number Do you have a Class A or B CDL? Yes No If yes, what, if any, endorsements do you have?State of Issue 2) Have you been convicted of or pled guilty to any traffic-related offense within the past five years? Yes No 3) Have you had your driver’s license suspended or revoked or had your driving privileges modified by a court of law? Yes No 4. Please list all states from which you hold or have held a driver’s license Please use this space to list any special skills you may have that relate to the position applied for.Please list any professional licenses, designations, certifications, etc., that may relate to the position applied for. Include date granted, name of organization, and any other relevant information. APPLICANT'S CERTIFICATION AGREEMENT1. I authorize the investigation of all statements contained in this application and release from all liability any persons or employers supplying such information, and I also release the Company from all liability which might result from making the investigation. 2. I certify that the facts and information set forth in this application are true and complete to the best of my knowledge. I understand that any falsification, misrepresentation or omission of facts on this application (or on any required documents) may result in denial of employment or immediate termination of employment, regardless of when or how discovered. 3. I agree, if I am offered and accept a position, to conform to all existing and future Company rules and regulations and I understand that the Company reserves the right to change wages, hours and working conditions as deemed necessary. I ALSO UNDERSTAND THAT, IF HIRED, MY EMPLOYMENT WILL BE AT-WILL, MEANING THAT EITHER PARTY CAN END THE EMPLOYMENT RELATIONSHIP AT ANY TIME AND FOR ANY OR NO REASON. 4. I understand that any employment offer is contingent upon my providing, within three (3) working days of employment, valid proof of identity and eligibility to work in order to comply with the Immigration Reform and Control Act of 1986. 5. I have read and reviewed the information provided in this application and the above statements. By signing this application for employment I certify that I understand all parts of it and have answered all questions completely and fully. SignatureDate* Month Day Year Voluntary Self-Identification of “Protected” Veteran StatusWhy Are You Being Asked to Complete This Form? This employer is a Government contractor subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA). VEVRAA requires Government contractors to take affirmative action to employ and advance in employment protected veterans. To help us measure the effectiveness of our outreach and recruitment efforts of veterans, we are asking you to tell us if you are a veteran covered by VEVRAA. Completing this form is completely voluntary, but we hope you fill it out. Any answer you give will be kept private and will not be used against you in any way. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp. How Do You Know if You Are a Veteran Protected by VEVRAA? Contrary to the name, VEVRAA does not just cover Vietnam Era veterans. It covers several categories of veterans from World War II, the Korean conflict, the Vietnam era, and the Persian Gulf War which is defined as occurring from August 2, 1990 to the present. If you believe you belong to any of the categories of protected veterans please indicate by checking the appropriate box below. The categories are defined on the next page and explained further in an “Am I a Protected Veteran?” infographic provided by OFCCP. What Categories of Veterans Are “Protected” by VEVRAA? “Protected” veterans include the following categories: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and These categories are defined below. 1. A “disabled veteran” is one of the following: • a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or • a person who was discharged or released from active duty because of a service-connected disability. 2. A “recently separated veteran” 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, ground, naval, or air service. 3. An “active duty wartime or campaign badge veteran” means a veteran who served on active duty in the U.S. military, ground, naval or air service 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. 4. An “Armed forces service medal veteran” means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985. Please choose from one of the options below:* I IDENTIFY AS ONE OR MORE OF THE CLASSIFICATIONS OF PROTECTED VETERAN LISTED ABOVE I AM NOT A PROTECTED VETERAN I DO NOT WISH TO ANSWER Name* First Last Today's Date* MM slash DD slash YYYY EEO-1 Voluntary Self Identification Form The Equal Employment Opportunity Commission (EEOC) requires all private employers with 100 or more employees as well as federal contractors and first-tier subcontractors with 50 or more employees AND contracts of at least $50,000 complete an EEO-1 report each year. Covered employers must invite employees to self-identify gender and race for this report. Completion of this form is voluntary and will not affect your opportunity for employment, or the terms or conditions of your employment. This form will be used for EEO-1 reporting purposes only and will be kept separate from all other personnel records only accessed by the Human Resources department. Please return completed forms to the HR department. If you choose not to self-identify your race/ethnicity at this time, the federal government requires Jim Smith Contracting to determine this information by visual survey and/or other available information. Name* First Last Today's Date* MM slash DD slash YYYY Gender*GenderMaleFemaleRace / Ethnicity*RaceHispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.White (Not Hispanic or Latino): A person having origins in any of the original peoples of Europe, the Middle East or North Africa.Black or African American (Not Hispanic or Latino): A person having origins in any of the black racial groups of Africa.Third ChoiceNative Hawaiian or Pacific Islander (Not Hispanic or Latino): A person having origins in any of the peoples of Hawaii, Guam, Samoa or other Pacific Islands.Asian (Not 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.Native American or Alaska Native (Not Hispanic or Latino): A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment.Two or more races (Not Hispanic or Latino): All persons who identify with more than one of the above five races.I do not wish to disclose. Voluntary Self-Identification of Disability Why are you being asked to complete this form? We are a federal contractor or subcontractor required by law to provide equal employment opportunity to qualified people with disabilities. We are also required to measure our progress toward having at least 7% of our workforce be individuals with disabilities. To do this, we must ask applicants and employees if they have a disability or have ever had a disability. Because a person may become disabled at any time, we ask all of our employees to update their information at least every five years. Identifying yourself as an individual with a disability is voluntary, and we hope that you will choose to do so. Your answer will be maintained confidentially and not be seen by selecting officials or anyone else involved in making personnel decisions. Completing the form will not negatively impact you in any way, regardless of whether you have self-identified in the past. For more information about this form or the equal employment obligations of federal contractors under Section 503 of the Rehabilitation Act, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp. How do you know if you have a disability? You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition. Disabilities include, but are not limited to: • Autism • Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, or HIV/AIDS • Blind or low vision • Cancer • Cardiovascular or heart disease • Celiac disease • Cerebral palsy • Deaf or hard of hearing • Depression or anxiety • Diabetes • Epilepsy • Gastrointestinal disorders, for example, Crohn's Disease, or irritable bowel syndrome • Intellectual disability • Missing limbs or partially missing limbs • Nervous system condition for example, migraine headaches, Parkinson’s disease, or Multiple sclerosis (MS) • Psychiatric condition, for example, bipolar disorder, schizophrenia, PTSD, or major depression Yes, I Have A Disability, Or Have A History/Record Of Having A Disability* Yes, I Have A Disability, Or Have A History/Record Of Having A Disability No, I Don’t Have A Disability, Or A History/Record Of Having A Disability I Don’t Wish To Answer CAPTCHAAnti-Spam Question: What day comes after Sunday? CommentsThis field is for validation purposes and should be left unchanged.
