Name: __________________________________________________________Date:__________________

Address:_______________________________________________________________________________

Telephone:____________________________________Cell:_____________________________________

 Are you authorized to work in the US on an unrestricted basis?   YES          NO

 Are you over the age of 18?           YES          NO

Have you been told the essential functions of the job or been shown a copy of the job description listing the essential functions of the job?       YES         NO

If yes, can you perform these essential functions with or without reasonable accommodation?             YES           NO

List any hours, shifts or days you cannot work:________________________________________________

 Are you seeking:               PART TIME                     FULL TIME     

Are you willing to work overtime if required?          YES                  NO

Have you ever been convicted of or pleaded no contest to a felony charge?     YES        NO

(Conviction will not necessarily disqualify an applicant for employment)  

If yes, Describe conditions:________________________________________________________________  

Education

Name & Location of School

 

Years Completed  

Major

Diploma/ Degree

High School  

 

 

 

 

College / Univ.  

 

 

 

 

College/ Univ.  

 

 

 

 

Other Training or Education:

 

 

 

 

In addition to education, what other experience, skills or qualifications do you feel should be brought to our attention in the case that they make you especially suited for working with us: ______________________________________________________________________________________

  ______________________________________________________________________________________  

  Position(s) applied for: 1._________________________________2._______________________________

  Wage or salary desired: $_____________________per_____________ Date you can start: _____________

Previous Employment Information:

Name:

 

Address:

Telephone:

Date Started:

Starting Position:

Starting Wage

$_____________________ per ________________

Date Left:

Ending Position:

Departing Wage

$______________________per________________

Description of Duties:

Reason for Leaving:

Name & Title of Supervisor:

 

       

Name:

 

Address:

Telephone:

Date Started:

Starting Position:

Starting Wage

$_____________________ per ________________

Date Left:

Ending Position:

Departing Wage

$______________________per________________

Description of Duties:

 

Reason for Leaving:

Name & Title of Supervisor:

 

       

Name:

 

Address:

Telephone:

Date Started:

Starting Position:

Starting Wage

$_____________________ per ________________

Date Left:

Ending Position:

Departing Wage

$______________________per________________

Description of Duties:

 

Reason for Leaving:

Name & Title of Supervisor:

 

       

I certify that the facts set forth in this application are true and complete to the best of my knowledge. I understand that if I am employed, false statements, omissions or misrepresentations may result in my dismissal.  I authorize the company to make an investigation of any of the facts set forth in the application.  I further understand that employment at this company is “at- will”, which means that either I or the company can terminate my employment at any time, with or without prior notice, for any reason not prohibited by statue.

 It is our policy to comply with all applicable state and federal laws prohibiting discrimination in employment based on race, age, color, sex, religion, national origin or other protected classifications.

Our mission is to ensure that the workplace is ran safely, efficiently and effectively by establishing a drug and alcohol- free work environment and to ensure that the workplace remains free from the effects of drugs and alcohol in order to promote the health and safety of employees and the general public.  In keeping with this mission, Maupin’s declares that the unlawful manufacture,

distribution, dispense, possession or use of controlled substances or misuse of alcohol is prohibited for all employees.  Additionally, the purpose of this policy is to establish guidelines to maintain a drug and alcohol- free workplace in compliance with the Drug- Free Workplace Act of 1998.  This policy is intended to comply with all applicable Federal regulations governing workplace anti- drug and alcohol programs in the US Act of 1998, all employees are required to notify Maupin’s management of any criminal drug stature conviction for a violation occurring in the workplace within five days after such conviction.  The Drug and Alcohol Testing Policy applies to all employees.  Participation in a drug and alcohol testing program is a mandatory condition of employment.

Prospective employees must pass a pre- employment drug test.  You will be required to submit a urine specimen at a designated collection site for the following drug substances: marijuana, cocaine, opiates, phencyclidine (PCP) and amphetamines.  You must pass this drug test to continue employment.  If hired, you will be subject to further urine drug and breath alcohol testing on a random unannounced basis, or when there is reasonable cause to believe you have used prohibited substances.

 

Name: _______________________________________________________________________________Date:__________________