Application for Employment Step 1 of 5 - Background Information 0% AN EQUAL OPPORTUNITY EMPLOYER M/F/V/HDRUG FREE WORKPLACE This application is active for 90 days from the date on the application. If you want to be considered again, you need to reapply.Date of Application* MM slash DD slash YYYY Position(s) Applied For Name First Last Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code TelephoneEmail Social Security Number* If employed and are you under 18, can you furnish a work permit? Yes No Have you filed an application here before? Yes No Date Filed Month Day Year Have you ever been employed here before? Yes No Employment Date Month Day Year Are you employed now? Yes No May we contact your employer? Yes No Are you on a lay-off and subject to recall? Yes No Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?(Proof of eligibility for employment in the U.S. will be required upon employment.) Yes No On what date would you be available for work? MM slash DD slash YYYY Are you seeking to work: Full-Time Part-Time Temporary Are you willing to work: First Shift Second Shift Third Shift Can you travel if a job requires it? Yes No Have you been convicted of a felony?(Conviction will not necessarily disqualify applicant from employment.) Yes No If Yes, please explain EMPLOYMENT EXPERIENCEStart with your present or last job. Include military service assignments and volunteer activities. If more space is required, continue entries on a separate sheet arranged as below and attach to application. Resumes are welcome, but may not be substituted for completion of the information requested below.Employer Name TelephoneAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Job Title Supervisor Dates of EmploymentFrom MM slash DD slash YYYY To MM slash DD slash YYYY Salary/Hourly RateStartingFinalReason for leaving Work Performed Add more work experience? Yes No Employer Name TelephoneAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Job Title Supervisor Dates of EmploymentFrom MM slash DD slash YYYY To MM slash DD slash YYYY Salary/Hourly RateStartingFinalReason for leaving Work Performed Add more work experience? Yes No Employer Name TelephoneAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Job Title Supervisor Dates of EmploymentFrom MM slash DD slash YYYY To MM slash DD slash YYYY Salary/Hourly RateStartingFinalReason for leaving Work Performed Add more work experience? Yes No Employer Name TelephoneAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Job Title Supervisor Dates of EmploymentFrom MM slash DD slash YYYY To MM slash DD slash YYYY Salary/Hourly RateStartingFinalReason for leaving Work Performed EDUCATIONSelect the highest grade completed 1 2 3 4 5 6 7 8 9 10 11 12 12+ High School Name Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Did you graduate? Yes No GED Please list Technical School(s), College, etc.(include major, years completed and if degree was received)Special Skills / QualificationsPlease list any specialized training, apprenticeship or other skills that may be helpful to us in considering your application.ReferencesPlease list names, addresses and telephone numbers or three references who are NOT RELATED TO YOU. NOTICE OF DRUG SCREEN (Pre-Employment):VERSEVO Inc. is concerned with the health and safety of all of its employees. Consistent with this philosophy, we strive to create a “drug/alcohol” free work environment. In order to be qualified for employment at VERSEVO Inc., each person offered employment with VERSEVO Inc. will be required to pass a drug screen. This drug screen will require prospective employees to provide a urine sample. A confirmed positive test result, or refusal to submit to a drug screen, will disqualify that person from further consideration for employment with VERSEVO Inc.APPLICANT’S STATEMENT, AUTHORIZATION AND RELEASE:Applicant’s Name (please print): 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. I authorize VERSEVO Inc. to contact previous employers to verify my past employment record and authorize prior employers to release such information to VERSEVO Inc. representatives. I recognize that a copy of this authorization and release is as valid as the original and should be considered as such. I understand that this application is not and is not intended to be a contract of employment. In the event of my 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 Company. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal laws and state laws.Digital Signature*By checking the box below, I acknowledge I am digitally submitting my signature for this application. Confirm Date MM slash DD slash YYYY Applicant Data RecordApplicants 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 disability. As employers/government contractors, 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 Data Record. We appreciate you cooperation. This data is for periodic government reporting and will be kept in a Confidential File separate from the Application for Employment.Date MM slash DD slash YYYY Name First Middle Last Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Position(s) Applied For: Referral Source Advertisement Walk-In Employee Affirmative Action SurveyGovernment agencies require periodic reports on the sex, ethnicity, disability and veteran status of applicant. This data is for analysis and affirmative action only. Submission of information is voluntary.Gender Identity Male Female Choose one of the following race/ethnic group White Black/African American Hispanic Asian/Other Pacific Islander American Indian or Alaskan Native NameThis field is for validation purposes and should be left unchanged.
