EQUAL OPPORTUNITY

EMPLOYMENT DATA FORM

 

Text Box: The following voluntary information is used to monitor our Affirmative Action Program. The information your are being asked to provide is the result of a federal requirement under Executive Order 11246. It will be used for reporting of applicant flow statistics and determining effective methods of advertising. Employees and applicants for employment who wish to benefit under the affirmative action programs for qualified disabled persons and Vietnam Era/Special Disabled Veterans are invited to self-identify. The information is voluntary, will be kept confidential, and will not subject the applicant or employee to any adverse treatment. The information is used in accordance with Sections 503 of the Rehabilitation Act of 1973 and Sections 402 of the Vietnam Era Veterans Readjustment Assistance Act of 1974, as amended. Please note that a request to benefit under the affirmative action program may be made immediately or at any time in the future.

 

 

Name:________________________________________________________________________

                                Last                                                            First                                                            Middle

 

Address:______________________________________________________________________

                                                   Street                                                         

 

______________________________________________________________________________

                 City                                                                                               State                         Zip Code                 County

 

 

Position Applied for: ____________________________________________________________

 

How did you hear about this position: ___________________________________________­­­­­­­____

 

 

Sex                                                              □ Male                                                       □ Female

 

Disabled                                                   □ Yes                                                          □ No

 

Age                                                             □ 18-25   □ 26-35   □ 36-45   □ 46 +

 

Race (check all that apply)             □ White                                     □ Black or African American

                                                                    □ American Indian or                            □ Asian

   Alaska Native

□ Hispanic or Latino                             □ Native Hawaiian or

                                                                       Other Pacific Islander

 

Vietnam Era Veteran        □ No                                                           □ Yes (DD 214 required)

Disabled Veteran                                 □ No                                                           □ Yes (VA certification required)

Last Name

First Name

Middle Initial

Social Security Number

                   --               --   

Drivers License Number & State

Street Address

Phone Number

Alternate Phone Number

City

State

Zip Code

Message Number

E-Mail Address

Emergency Contact:

Relationship:

Telephone Number:

Education                   School Name, Location

Degree or

Course Study

High School

 

Vocational

 

College

 

Are there any limitations that with or without reasonable accommodations, might prevent you from performing the    essential functions encountered while working in a metal fabrication shop.  i.e. lifting (up to 50lbs) repetitively, standing, stooping, bending, kneeling, sitting.

Yes               No

Please Explain:

Have you ever been convicted of a felony?  (A “Yes” answer will not bar you from consideration for employment.  False information is grounds for immediate discharge if employed at a later date)

 

Yes               No

Please Explain:

Company

Supervisor

Work Performed

Hrs / Week

Address

Start Date (Month/Year)

End Date (Month/Year)

State Reason’s for Leaving (Please be Specific)

Telephone Number

Starting Wage

Ending Wage

Company

Supervisor

Work Performed

Hrs / Week

Address

Start Date (Month/Year)

End Date (Month/Year)

State Reason’s for Leaving (Please be Specific)

Telephone Number

Starting Wage

Ending Wage

Company

Supervisor

Work Performed

Hrs / Week

Address

Start Date (Month/Year)

End Date (Month/Year)

State Reason’s for Leaving (Please be Specific)

Telephone Number

Starting Wage

Ending Wage

Company

Supervisor

Work Performed

Hrs / Week

Address

Start Date (Month/Year)

End Date (Month/Year)

State Reason’s for Leaving (Please be Specific)

Telephone Number

Starting Wage

Ending Wage

APP

HIS

MSC

TST