NATIONAL
DISTRIBUTION
631.218.6604

EMPLOYMENT APPLICATION

How were you referred to us:
Position Applying for: Check one
No Preference / unsure
Supervisor
Mechanic
Production
Sanitation/Production
Janitorial
Shift Preferred:
No Preference
8 am – 4 pm
4 pm – 12 am
12 am – 8 am (shift differential)
Name Phone
Email Address
Date Available to Start Salary Desired
If you are under 18 years of age, can you provide a work permit? Yes No
If no, please explain:

Have you ever worked for this company? Yes No
If yes, when:

Are you legally allowed to work in the United States? Yes No

Have you ever been terminated or asked to resign from a job? Yes No
If yes, how many times?

Has your employment ever been terminated by mutual agreement? Yes No
If yes, how many times?

Have you ever been given the choice to reason rather than be terminated? Yes No
If yes, how many times?

If you answered Yes to any of the above three questions, please explain the circumstances of each occasion.

WORK EXPERIENCE

Please list the names of your present and/or previous employers in chronological order with present or most recent employer listed first. Provide information for at least the most recent three (3) year period. Attach additional sheets if needed. If self-employed, supply firm name and business references. You may include any verifiable work performed on a volunteer basis, internships, or military service. Your failure to completely respond to each inquiry may disqualify you for consideration from employment. This can be replaced by resume if you provide us a copy.

Employer
Name Address Type of Business
Telephone Dates Employed
From To
Job Title Duties
Supervisor's Name May we contact? Yes No. If No, why not?
Wages: Start Final Reason for Leaving
What will this employer say was the reason your employment terminated?

How much notice did you give when resigning?

If None, explain.

Employer
Name Address Type of Business
Telephone Dates Employed
From To
Job Title Duties
Supervisor's Name May we contact? Yes No. If No, why not?
Wages: Start Final Reason for Leaving
What will this employer say was the reason your employment terminated?

How much notice did you give when resigning?

If None, explain.

Employer
Name Address Type of Business
Telephone Dates Employed
From To
Job Title Duties
Supervisor's Name May we contact? Yes No. If No, why not?
Wages: Start Final Reason for Leaving
What will this employer say was the reason your employment terminated?

How much notice did you give when resigning?

If None, explain.


NOTES




New Employee Self-Identification Form*

Federal laws and regulations require us to report on our workforce by race, gender, and veteran status and to offer the opportunity for self-identification as to disabilities. Please assist us by completing this form. YOU ARE NOT REQUIRED TO PROVIDE THIS INFORMATION. Data which you provide shall be kept strictly confidential, except that (i) supervisors and managers may be informed regarding restrictions on the work or duties of disabled individuals and/or disabled veterans; (ii) first aid and safety personnel may be informed, to the extent appropriate, if the condition might require emergency treatment; and (iii) governmental officials reviewing the Company’s compliance status shall be informed.
Last Name: First Name:
Middle Initial: (Optional) Social Security Number:

Gender: Please place a check next to the appropriate category.
MALE FEMALE

Race/Ethnicity: Please check one.
Hispanic or Latino
Black or African American (Not Hispanic or Latino)
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)
American Indian or Alaska Native (Not Hispanic or Latino)
White (Not Hispanic or Latino)
Asian (Not Hispanic or Latino)
Two or More Races (Not Hispanic or Latino)

Veteran Status: Check all that apply.
I am a disabled veteran.†
I am a recently separated veteran.† --- Date of discharge:
I served on active duty during a war or in a campaign or expedition for which a campaign badge has been authorized.
I participated in a United States military operation for which an Armed Forces Service Medal was awarded, while serving on active duty in the Armed Forces, pursuant to Executive Order No. 12985 (61 Fed. Reg. 1209).

Disability
I am an individual with a disability.*
I have received the form and decline to provide the requested information.


* Categories consistent with 41 C.F.R. §60-300 & Form VETS-100A
If you need a definition of these terms, please see below.

SELF-IDENTIFICATION FORM DEFINITIONS
  1. The term "Disabled Veteran" means –
    1. A veteran 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 Department of Veterans Affairs for a disability; or
    2. A person who was discharged or released from active duty because of a service-connected disability.
  2. The term "Recently Separated Veteran" applies to any veteran during the three -year period beginning on the date of discharge or release from active duty.
  3. An “individual with a disability” means any person who (i) has a physical or mental impairment which substantially limits one or more of such person’s major life activities; (ii) has a record of such impairment; or (iii) is regarded as having such impairment.

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