Application for Employment We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of non-job- related medical condition or disability, or any other legally protected status. Position(s) Applied For 1. 2. Date How Did You Learn About Us? * Advertisement Friend Walk-In Employment Agency Relative Other Last Name First Name Middle Name Address Number Street City State Zip Code Telephone Number (s) Social Security Number If you are under 18 years of age, can you provide required proof of your eligibility to work?YesNo Have you ever filed an application with us before?YesNo If yes, give date and location Have you ever been employed with any CCI Company before?YesNo If yes, give date and location Are you currently employed?YesNo Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? Proof of citizenship or immigration status will be required upon employment.YesNo On what date would you be available for work? Are you available to work: Full Time Part Time Shift Work Temporary Shift preferred: Day Night Are you currently on “lay-off” status and subject to recall?YesNo Can you travel if a job requires it?YesNo Can you work overtime, nights, weekends and/or holiday shifts when necessary?YesNo Do you have any pre-existing injuries and or diseases that you know of, that may be affected by the proposed employment?YesNo Have you been convicted of a felony Conviction will not necessarily disqualify an applicant from employment.YesNo If Yes, please explain WE ARE AN EQUAL OPPORTUNITY AFFIRMATIVE ACTION EMPLOYER Education Elementary School High School Undergraduate College / University Graduate / Professional School Name and Location Years Completed ---45678 ---9101112 ---1234 ---1234 Diploma / Degree / Mo/Yr Completed Describe Course of Study Date Completed: Date Completed: Describe any specialized training,apprenticeship, skills and extra-curricular activities Describe any honors you have received State any additional information you feel may be helpful to us in considering your application Indicate any foreign languages you can speak, read and / or write FLUENT GOOD FAIR SPEAK READ WRITE List professional, trade, business or civic activities and offices held. You may exclude memberships which would reveal sex, race, religion, national origin, age,ancestry, or disability or other protected status. For positions requiring office equipment skills- Indicate office machines you operate and skill level. Typing (speed: Dictaphone (transcription speed: Shorthand (speed: P.C. (model: Software: Have you ever had any job-related training in the United States Military?YesNo If Yes, please describe Employment Experience Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, sex, national origin, disability or other protected status. 1. Employer (Most Recent) Dates Employed From To Work Performed Address Telephone Hourly Rate/Salary Starting Final Job Title Supervisor May we contact?YesNo Reason for Leaving 2. Employer (Most Recent) Dates Employed From To Work Performed Address Telephone Hourly Rate/Salary Starting Final Job Title Supervisor May we contact?YesNo Reason for Leaving 3. Employer (Most Recent) Dates Employed From To Work Performed Address Telephone Hourly Rate/Salary Starting Final Job Title Supervisor May we contact?YesNo Reason for Leaving Please explain fully any gaps in your employment history. Special Skills and Qualifications Summarize special job-related skills and qualifications acquired from employment or other experience. IN CASE OF EMERGENCY NOTIFY Name Telephone No. Address Thank you for completing this application form and for you interest in employment with us. We would like to assure you that your opportunity for employment with this company will be based on your merit and on no other consideration. Applicant Data Record Applicants are considered for all positions, and employees are treated during employment without regard to race, color, religion, sex, national origin, age, marital or veteran status, medical condition or handicap. As an employer/government contractor, we comply with government regulations and affirmative action responsibilities. Solely to help us comply with government record keeping, reporting and other legal requirements, please fill out the Applicant Data Record. We appreciate your cooperation. Refusal to provide this information will not subject you to adverse treatment. This data is for periodic government reporting and will be kept in a Confidential File separate from the Application for Employment. (PLEASE PRINT) Position(s) Applied for Date Referral Source: Advertisement Friend Walk-In Employment Agency Relative Other Last Name First Name Middle Name Address Number Street City State Zip Code Area Code Applicant’s Statement I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. This application for employment shall be considered active for a period of time not toexceed 90 days. Any applicant wishing to be considered for employment beyond this time period should inquireas to whether or not applications are being accepted at that time. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer. I agree that the company reserves the right to require me to submit to a drug / alcohol test prior to employment and at any time during my employment, to the extent permitted by law. I also understand that if I should receive a conditional offer of employment I may be required to submit to a medical examination or medical inquiries to determine my ability to perform the essential functions of the job for which I have applied. Applicant’s Signature FOR HUMAN RESOURCES DEPARTMENT USE ONLY Date Called By whom Eligible YesNo Arrange Interview YesNo Interview Date: Hour: Remarks Employed YesNo Date of Employment INTERVIEWER DATE Job Title Hourly Rate / Salary Department By: NAME AND TITLE DATE Disclosure/Release of Liability I ,Date of Birth (month and day only if used for employment) Social Security Number , do hereby authorize Carolina Constructions & Industrial Services (CCI Services) of Fayetteville, NC to conduct a background investigation into the following areas of my personal and employment history, current and previous employment, education, credit, driving records, criminal and civil records, professional licensing, and general character including honesty. My driver’s license number is and was issued on Sex: MaleFemale ADDRESS INFORMATION Current Address Length at current address (if less than 7 years please provide previous address) Previous address (1) Previous address (2) Length at previous address (1) , Length at previous address(2) AUTHORIZATION AND RELEASE I hereby authorize any person, agent, corporation, company, agency, or institution to release any information, document, or assessments they posses regarding me or my performance as an employee, student, associate, or acquaintance. I release and permanently hold harmless, CCI Services their agents and assigns, and the REQUESTER and their agents and assigns, from any and all demands and or liabilities that may originate from these investigations, or any demand or liability which may result from any physical examination, drug testing procedure, x-rays, or other medical screening procedures conducted by them or their agents and any person, corporation, company institution, or their agents who may act upon the authority of this release. I hereby authorize that a photocopy or electronic facsimile of this document shall serve as an original. If a notarized copy of this document is required for any background check, the notarized copy will be provided. Applicant Signature DATE Recognition I certify that the answers given in this document are true and complete to the best of my knowledge.