Employment Form Applicant Employment Form Don Luchetti Construction565 Distribution DrMelbourne, FL 32904 We are an equal opportunity employer and do not unlawfully discriminate in employment. No question on this application is used for the purpose of limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Equal access to employment, services, and programs is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the organization. If offered a position and prior to hiring, all applicants will be verified in e-Verify System and will be sent for drug testing.Name* First Middle Last Position(s) applied for or type of work desired* Full-time/Part-Time/Temporary Full-time Part-time Temporary Date you will be available to begin working* Address* Street Address City State 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 ZIP Code Phone*Alt. PhoneEmail* Social Security Number* Birth Date* Are you able to meet the attendance requirements?* Yes No Do you have any objection to working overtime if necessary?* Yes No Do you have your own transportation?* Yes No Can you travel if required by this position?* Yes No Have you ever been previously employed by our organization?* Yes No Can you submit proof of legal employment authorization and identity?* Yes No If you are under 18, can you furnish a work permit if it is required?* Yes No Do you have any objection for us to do a Pre-Employment Background Check?* Yes No Do you have any objection to taking a Drug Screening Test? If, you are considered for the position?* Yes No Have you ever been convicted of a crime in the last 7 years?* Yes No If yes, please explain (a conviction will not automatically bar employment):* Drivers license number (if driving is an essential job duty): How were you referred to us? Educational HistoryList school name and location, years completed, course of study, and any degrees earned:Highschool* Did you graduate? Yes No College Did you graduate? Yes No Other Did you graduate? Yes No Previous EmploymentEmployer 1 Name, Address and telephone #* Position held* Immediate Supervisor and their title* Dates Employed* Salary* Job summary* Reason for leaving* Employer 2 Name, Address and telephone # Position held* Immediate Supervisor and their title* Dates employed* Salary* Job Summary* Reason for leaving* Employer 3 Name, Address and telephone # Postion held Immediate Supervisor and their title Dates employed Salary Job Summary Reason for leaving Employer 4 Name, Address and telephone # Position held Immediate Supervisor and their title Dates employed Salary Job Summary Reason for leaving Other Skills and QualificationsSummarize any job-related training, skills, licenses, certificates, and/or other qualifications:ReferencesList 3 references names, telephone numbers, and years known (do not include relatives or employers): Upload a resumeMax. file size: 2 MB.Disclaimer & Signature I hereby authorize the potential employer to contact, obtain, and verify the accuracy of information contained in this application from all previous employers, educational institutions, and references. I also hereby release from liability the potential employer and its representatives for seeking, gathering, and using such information to make employment decisions and all other persons or organizations for providing such information. I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered. If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either I or the employer can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law. I understand that it is the policy of this organization not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that person’s need for a reasonable accommodation as required by the ADA. I also understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment. I represent and warrant that I have read and fully understand the foregoing, and that I seek employment under these conditions.This Application Is Not Complete WIthout Your Signature* Date* MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged. EEO DATA RECORD All applicants must fill out this form as well to be considered for positions EEO DATA RECORDApplicants are considered for all positions for which they are qualified. Applicants and employees will be treated during the selection process and employment without regard to race, color, religion, sex, national origin, age, marital status, or veteran's status, medical condition, or disability. As an employer and government contractor, we comply with government regulations and our affirmative action responsibilities. Solely to help us to comply with government record keeping, reporting and other legal requirements, please fill out this Applicant Data Record. We appreciate your cooperation. This data is periodic government reporting and will be kept in a Confidential File separate from the Application for Employment.Date Name Address Position Applied For Referral Source Advertisement Relative/Friend Walk-In Tech School College Recruitment Community Employment Agency State Employment Agency Private Employment Agency Current Employee Name of employee who referred you (if any) AFFIRMATIVE ACTION SURVEYGovernment agencies require periodic reports on the sex, ethnicity, veteran, and disability status of applicants. This data is for analysis and affirmative action only. Submission of information is voluntaryGender Identification (Check One): Male Female Race/Ethnic Identification (Check One): Hispanic or Latino - (A person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin regardless of race If not Hispanic or Latino IF you did not check "Hispanic or Latino" above, please check one of the following race/ethnic identificationsAdditional race/ethnic identifications White (Not Hispanic or Latino) - A person having origins in the original peoples of Europe, North Africa or the Middle East Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa Asian (Not Hispanic or Latino - Persons having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent for example: Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Phillipine Islands, Thailand and Vietnam. Native Hawaiian or Other Pacific Islanders (Not Hispanic or Latino) - Persons having origins in Hawaii, Guam, Samoa or the Pacific American Indian or Alaskan Native (Not Hispanic or Latino) - Persons having origins in any of the original peoples of North American, and who maintain a cultural identification through tribal affiliation or community recognition. Two or more races (Not Hispanic or Latino) - All persons who identify with more than one of the above five races. ADDITIONAL IDENTIFICATION CATEGORIESAs a government contractor subject to Section 503 of the Rehabilitation Act of 1973 and Section 402 of the Vietnam Era Veterans Readjustment Act of 1974, we employ and advance in employment qualified individuals with disabilities, disabled veterans, Vietnam era veterans, and other qualified veterans. Status as a qualified veteran includes special disabled veterans, veterans of the Vietnam era, or any other veteran who served on active duty during a war or campaign or expedition for which a campaign has been authorized. If you are an individual with a disability, a disabled veteran, or other qualified veteran, you are invited to volunteer this information. The purpose of this information is regulatory record keeping requirements to determine good faith efforts and affirmative action, or to provide affirmative action. This information will not adversely affect any employment decision nor will engaging in activities based on equal opportunity and affirmative action law including: 1) Filing a complaint, 2) Cooperating in an investigation, 3) Opposing any unlawful act or practice made unlawful, or 4) Exercising any other right protected under equal opportunity law.If you wish to self-identify, please check all that apply and sign below: Disabled Veteran - 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 Veteran Affairs, or a person who was discharged or released from active duty because of service-connected disability. Other Protected Veteran - 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. Armed Forces Service Medal - 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 Armed Forces service medal was awarded pursuant to Executive Order 12965 (61 Fed. Reg. 1209) Recently Separated Veteran - A 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. Signature and Date
