Application For Employment

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Application for Employment

Employment Experience

The number of employment experience you have had before:(*)

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Employer One

Employer(*)

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Contact Name(*)

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E-mail(*)

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Address(*)

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Phone(*)

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Job Title(*)

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Supervisor(*)

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Dates employed:

From (mm-dd-yyyy)

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To (mm-dd-yyyy)

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Work Performed(*)

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Reason for leaving(*)

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Employer Two

Employer(*)

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Contact Name(*)

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E-mail(*)

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Address(*)

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Phone(*)

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Job Title(*)

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Supervisor(*)

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Dates employed:

From (mm-dd-yyyy)

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To (mm-dd-yyyy)

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Work Performed(*)

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Reason for leaving(*)

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Employer Three

Employer(*)

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Contact Name(*)

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E-mail(*)

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Address(*)

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Phone(*)

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Job Title(*)

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Supervisor(*)

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Dates employed:

From

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Work Performed(*)

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Reason for leaving(*)

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Employment Experience (continued)

Explain any gaps in your employment, other than those due to personal illness, injury or disability

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Have you ever been fired or asked to resign from a job?

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If yes, Please explain:

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Voluntary Disclosure

Individuals seeking employment are considered without regard to race, color, religion, creed, sex, age, national origin, citizenship status, disability status, sexual orientation, gender identity or expression, pregnancy, genetic information, protected military and veteran status, ancestry, marital status, medical condition (cancer and genetic characteristics) or any other characteristic protected by law. You are being given the opportunity to provide the following information in order to help us comply with federal and state Equal Employment Opportunity/Affirmative Action record keeping, reporting, and other legal requirements.

Gender(*)

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Veteran Status(*)

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Ethnicity(*)

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Privacy

I explicitly and unambiguously consent to the collection, use or transfer in electronic or other form, of my Personal Data to Case Medical and its Affiliates, or any third parties (“Recipients”) assisting in the recruitment activities. “Personal data” includes, but is not limited to, name, home address, telephone number, date of birth, salary information, job title. “Recruitment activities” includes the activities associated with a job seeker application and Case Medical's review and decision making regarding the application.

(*)

Yes, I have read and consent to the terms and conditions

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Voluntary Self-Identification of Disability

Name(*)

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Date(*)

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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. To do this, we must ask applicants and employees if they have a disability or have ever had a disability.

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 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

Please check one of the boxes below:(*)

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

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Applicant Statement

I certify that all the information submitted by me on this application is true and complete, and I understand that if any false or misleading information, omissions or misrepresentations are discovered, my application may be rejected, and if I am employed, my employment may be terminated at any time.

If hired, I agree to conform to the Company's rules and regulations, and I understand that these rules and/or the employee handbook do not form a contract of employment either express or implied, and I agree that my employment and compensation can be terminated, with or without cause and with or without notice, at any time, at either my or the Company's option.

I also understand and agree that the terms and conditions of my employment may be changed, with or without cause and with or without notice, at any time by the Company. I understand that no Company representative, other than its CEO, and then only when in writing and signed by the CEO, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives for seeking, gathering and using truthful and nondefamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that this application remains for only 60 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.

I also understand that, if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States as required by federal immigration laws.

This company does not tolerate unlawful discrimination or harassment based on sex, race, color, religion, national origin, citizenship, age, disability, or any other protected status under applicable federal, state or local law. No question on this application is used to limit or exclude an applicant from employment consideration on any basis prohibited by applicable federal, state or local law.

Applicant's Signature(*)

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Date(*)

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