How much time have you lost from work or school during the past two calendar years FOR REASONS OTHER THAN VACATION AND HOLIDAYS?
Please list 2 Business and 2 Personal. (NOTE: for Business, list only those persons who held managerial positions during the time of your employment.)
1. Certification of Truthfulness.
I certify that all statements on this Application for Employment are complete and truthful and agree that such statements may be investigated and if found to be false will be sufficient reason for not being employed, or if employed may result in my dismissal.
2. Authorization for Employment/Educational Information.
I authorize the references listed in this Application for Employment, and any prior employer, educational institution, or any other persons or organizations to give this Company any and all information concerning my previous employment/educational accomplishments, disciplinary information or any other pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you. I hereby waive written notice that employment information is being provided by any person or organization.
3. Employment at Will.
If I am hired, in consideration of my employment, I agree to abide by the rules and policies of this Company, including any changes made from time to time, and agree that my employment and compensation can be terminated with or without cause, and with or without notice, at any time, at the option of either the Company or myself. I understand that no manager or other representative of the Company, other than the President, has any authority to enter into any agreement for employment for any specific or indefinite period of time, or to make any agreement contrary to the foregoing. Any such agreement made by the President must be made in writing to be effective.
4. Authorization to Work.
If I am selected for hire, I will be offered employment provided I verify that I am authorized to work as required by the Immigration Reform and Control Act of 1986.
5. Limitation on Claims.
I agree that any lawsuit or claim against the Company arising out of my employment or termination of employment (including, but not limited to, claims arising under state, federal or local civil rights laws) must be brought within the following time limits or be forever barred: (a) for lawsuits requiring a Notice of Right to Sue from EEOC, within 90 days after the EECO issues that Notice; or (b) for all other lawsuits, within (i) 180 days of the event(s) giving rise to the claim, or (ii) the time limit specified by statute, whichever is shorter. I waive any statute of limitations that exceeds this time limit.
6. Need for Accommodation.
If I have a mental or physical disability and require an accommodation to perform the job, I must notify the Company of that need in writing within 182 days after I knew or reasonably should have known that an accommodation was needed. Failure to do so will bar me from alleging that the Company has not accommodated me as required by law.
7. Criminal Records Check.
I authorize the Company to secure my criminal conviction history. I agree to execute the appropriate authorization if necessary to obtain such information.
8. Driving Record Check.
I agree to execute an authorization for this employer to inquire into, and obtain documents related to, any driving record from every state in which I have held a motor vehicle operator’s license or permit.
9. Release of Medical Information.
I authorize every medical doctor, physician or other health care provider to provide any and all information, including but not limited to, all medical reports, laboratory reports, X-rays or clinical abstracts relating to my previous health history or employment in connection with any examination, consultation, test or evaluation. I hereby release every medical doctor, health care personnel and every other person, firm, officer, corporation, association, organization or institution which shall comply with the authorization or request made in this respect from any and all liability. I understand that this release will not be sent to my physician or other health care provider until a conditional job offer has been made.
10. Physical Exam and Drug and Alcohol Testing.
I agree to take a physical exam following a conditional job offer. I also authorize the Company or its designated agent(s) to withdraw specimen(s) of my blood, urine, hair and/or other substances for chemical analysis. One purpose of this analysis is to determine or exclude the presence of alcohol, drugs or other substances. I understand that decisions concerning my employment may be made as a result of these tests.
11. Consideration for Employment.
I understand that my application will be considered pursuant to the Company's normal procedures for a period of thirty (30) days. If I am still interested in employment thereafter, I must reapply.
I agree that if any of the above commitments is ever found to be legally unenforceable as written, the particular commitment concerned shall be limited to allow its enforcement as far as legally possible.
I have read, understand, and agree to items 1 through 11 above. I knowingly and voluntarily acknowledge that with my signature below.