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Application for Employment

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					Mosaico                                                  554 East 10th Street                  Phone: 464-0970
Employment Services                                      Erie, PA 16503                        Fax: 464-0973
                                       Application for Employment

We consider applicants for all positions without regard to race, color, religion, creed,
gender, national origin, age, disability, marital or veteran status, sexual orientation, or
any other legally protected status.
                                    (PLEASE PRINT)
Position(s) Applied For                                                                            Date of Application


How Did You Learn About Us?
  Advertisement         Friend       Walk-In
  Relative             Other__________________________________________________

Last Name                                                           First Name                 Middle Name


Address          Number           Street                                  City                 State              Zip Code


Telephone Number(s)                                                                           Social Security Number


Email Address


If you are under 18 years of age, can you provide required
proof of your eligibility to work?                                                                       Yes                 No
Are you legally eligible for employment in the USA?                                                      Yes                 No
            Proof of identity & eligibility will be required upon hire.

Have you every filed an application with us before?                                                      Yes                 No
Have you ever been employed with us before?                                                              Yes         No
                                                                                       If yes, give date_______________
Are you currently employed?                                                                              Yes                 No
May we contact your present employer?                                                                    Yes                 No
On what date would you be available for work?                                                          ________________
Are you available to work:                        Full Time               Part Time     Temporary
                                                  1st Shift               2nd Shift     3rd Shift
Are you currently on “lay-off” status and subject to recall?                                             Yes                 No
Do you have a valid driver license?                                                                      Yes                 No
Specify Safety Equipment you own: _________________________________________
            (Examples: steel-toed work shoes, hearing protection, etc.)

Have you been convicted of a felony within the last 7 years?                                             Yes                 No
            Conviction will not necessarily disqualify an applicant from employment.

If yes, please explain ______________________________________________________
________________________________________________________________________
                                  WE ARE AN EQUAL OPPORTUNITY EMPLOYER
Employment Experience

Employer                                                                           Dates Employed                           Work Performed
                                                                      From                 To
Address

Telephone Number(s)                                                               Hourly Rate/Salary
                                                                       Starting               Final
Job Title                     Supervisor

Reason for Leaving

Employer                                                                           Dates Employed                           Work Performed
                                                                           From                 To
Address

Telephone Number(s)                                                               Hourly Rate/Salary
                                                                       Starting               Final
Job Title                     Supervisor

Reason for Leaving

Employer                                                                           Dates Employed                           Work Performed
                                                                           From                 To
Address

Telephone Number(s)                                                               Hourly Rate/Salary
                                                                       Starting               Final
Job Title                     Supervisor

Reason for Leaving

Employer                                                                           Dates Employed                           Work Performed
                                                                           From                 To
Address

Telephone Number(s)                                                               Hourly Rate/Salary
                                                                       Starting               Final
Job Title                     Supervisor

Reason for Leaving




            If you need additional space, please continue on a separate sheet of paper.

  List professional, trade, business or civic activities and offices held.
  You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status:
  ___________________________________________________________________________
  ________________________________________________________________
  ________________________________________________________________
Education

                                                                                   Years     Diploma
                   Name and Address of School               Course of Study
                                                                                 Completed   Degree

    High
   School


Undergraduate
   School


    Other
  (Specify)




                  Indicate any foreign languages you can speak, read and/or write:
   Speak

    Read

    Write




References
    1. _____________________________________________________________________
                    (Name)                                                    Phone #
        _____________________________________________________________________
                    (Address)
    2. _____________________________________________________________________
                    (Name)                                                    Phone #
        _____________________________________________________________________
                    (Address)
    3. _____________________________________________________________________
                    (Name)                                                    Phone #
        _____________________________________________________________________
                    (Address)
Applicant’s Statement
                                      PRE-EMPLOYMENT STATEMENT
                                (Please read very carefully before signing below.)

  I voluntarily agree that:

      1.   The information that I have provided on this application is true and complete to the best of my
           knowledge. Any misrepresentation or omission of information on my application, resume, or any
           other materials, or during ay interviews, can be justification for refusal of employment, or, if
           employed termination from Mosaico employ.
      2.   I authorize and request that all of my present and former employers and those individuals I have
           listed as personal references furnish information about my employment, work performance, abilities,
           and other qualities pertinent to my qualifications for employment, hereby releasing them from any
           and all liability for damages arising from furnishing the requested information.
      3.   I also affirm that I have not signed any kind of restrictive document creating any obligation to any
           former employer that would restrict my acceptance of employment.
      4.   In consideration of my employment, I agree to comply with the policies, rules, regulations, and
           procedures of Mosaico. I understand that my employment will be on an at-will basis which means
           that my employment can be terminated with or without cause or notice, any time, at the option of
           either Mosaico or me. I further understand that no manager or representative of Mosaico, other than
           the president, has any authority to enter into any agreement with me for employment for any
           specified period of time or to make any agreement different from or contrary to any Mosaico Policy.
           I further understand that any such agreement, if made, shall not be enforceable unless it is in writing
           and signed by me and by Mosaico’s president.
      5.   I acknowledge that I have read all of the above statements and that I understand them.
                     _________________________________________ ___________________
                               Signature of Applicant                                          Date




                                    FOR OFFICE USE ONLY
Arrange Interview Yes No
Remarks_____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
__________________________________________ _________________________________
                                                                      Interviewer                      Date
Employed Yes No                   Date of Employment ___________________________
Job Title________________ Hourly Rate/Salary _________ Department ________________
By__________________________________________________________________________
              Name and Title                                                                    Date
Applicant:                                                                  Date:                        h

                                           SKILLS & EXPERIENCE
                                General Office: Please check all that apply to you
Business Background:                           Computer Program:                     Bookkeeping:
□   Advertising                                □   Word                              □   Full Charge
□   Legal                                      □   Excel                             □   Trial Balance
□   Medical                                    □   Access                            □   A/P and A/R
□   Engineering/Tech                           □   PowerPoint                        □   Payroll
□   Insurance                                  □   Email
□   Accounting                                 □   Internet                          Clerical:
□   Research/Development                       □   Peachtree                         □   Alpha D/E
□   Human Resources                            □   QuickBooks                        □   Numeric D/E
□   Administrative                             □   Other __________________          □   Mail Room
□   Customer Service                                                                 □   Coding
□   Sales                                      Communications:                       □   Proofreading
□   Marketing                                  □   Receptionist                      □   Editing
□   Purchasing                                 □   Switchboard                       □   Teller
□   Other __________________                   □   Multi-line Phone                  □   Cashier
                                               □   Fax Machine                       □   Typing
                                               □   Copy Machine                      □   Other _________________
                                               □   Other __________________

                        Laborer Skills/Technical/Shop: Please check all that apply to you
Plastics:                                      Machining:                            Welding:
□   Injection Molding                          □   CNC Programming                   □   Mig
□   Mold Operator                              □   CNC Manual                        □   Tig
□   Assembly                                   □   Operator                          □   Stick
□   Packaging                                  □   Set-Up                            □   Arc
□   Set-Up                                     □   Drill Press                       □   Aluminum
□   Inspection                                 □   Micrometers
                                               □   Calipers                          Warehouse:
Other:                                         □   Blueprint Reading                 □   Jitney Driver/Forklift Op.
□   General Labor                              □   Punch Press                       □   Inventory
□   Construction                               □   Screw Machine                     □   Shipping/Receiving
□   Delivery                                   □   Drill Press                       □   Stockroom
□   CDL License                                                                      □   Material Handler
□   Electrician                                Additional Skills:
□   Quality Control                            □   _________________________
□   Electronics Assembly                       □   _________________________
□   Food Service                               □   _________________________
□   Supervisor/Group Leader                    □   _________________________
□   Landscaping                                □   _________________________
□   Painter                                    □   _________________________
□   Woodworking                                □   _________________________
MOSAICO                                554 East 10th Street           814-464-0970 phone
EMPLOYMENT SERVICES, INC.              Erie, PA 16503                 814-464-0973 fax

              DRUG AND ALCOHOL ABUSE POLICY STATEMENT

MOSAICO has established the following policy because we believe a drug-free work environment is
vital to everyone’s safety and in fostering the well-being and health of our Associates. The goal of
this policy is to respect our Associates as individuals while maintaining a safe and productive drug
and alcohol-free environment. The intent of this policy is to send a clear message that the illegal use
of drugs and alcohol is not compatible with employment at MOSAICO and at the companies we are
partnered with.

        It is a violation of company policy for an employee to make, possess, use, hand out, buy,
         sell, trade or offer for sale illegal drugs or otherwise engage in the illegal use of drugs or
         alcohol while on assignment.
        It is a violation of company policy for an employee to possess, use or report to work
         under the influence of illegal drugs or alcohol.
        It is a violation of company policy for an employee to use prescription drugs illegally.
         The appropriate use of legally prescribed medications is acceptable; however, MOSAICO
         and Management at the company where an Associate is assigned to work should be
         advised in advance of such use to avoid conflicts.
        MOSAICO has adopted testing practices to identify; employees who use illegal drugs or
         alcohol.

It shall be a condition of employment for all employees to submit to drug and alcohol testing under
the following circumstances:

   1. Where there is reasonable suspicion to believe that an Associate is using illegal drugs or
      alcohol.
   2. When an Associate is involved in an on-the-job accident that requires medical treatment.
   3. When a client company of MOSAICO requires testing as a condition of employment.
   4. As a part of a follow-up program to treatment for drug or alcohol abuse.

ASSOCIATES WHO ARE IN VIOLATION OF THIS POLICY OR REFUSE TO FOLLOW THIS
POLICY ARE SUBJECT TO TERMINATION.

Acknowledgment
I have read and understand MOSAICO’s policy on drug and alcohol abuse and my obligations as an
Associate. I further understand and agree that, as a condition of employment, I may be required to
submit to drug and alcohol testing. I consent to having the results of any screening tests for drugs
and alcohol disclosed to MOSAICO and release MOSAICO, the medical institutions and physician
involved, from any and all liability associated with providing such test results. I understand and
agree that at the time of testing, I may be required to sign forms of consent and release of liability as
are usual and customary. I also consent to medical information, relative to a work-related injury,
being provided to MOSAICO and its insurance Carrier and release MOSAICO, its’ Insurance
Carrier, the medical institutions and physicians involved, from any and all liability associated with
providing this information.

_______________________________                                       ________________
Associate’s Signature                                                 Date
                                   WORKER’S COMPENSATION PANEL
                                               for
                                           MOSAICO

             In the event of an emergency, please go to the nearest hospital for treatment!

                                  You must notify your supervisor immediately!

OCCUPATIONAL MEDICINE: all injuries                             ORTHOPEDICS: injured and broken bones
HealthSouth Occupational Medicine                               North Coast Orthopedics – Dr. Vincent Rogers
143 East 2nd Street                                             Lake Erie Orthopedics
Erie, PA 16507                                                  301 State Street, Suite 301H
814-878-1249                                                    Erie, PA 16507
                                                                814-453-5049
St. Vincent Occupational Health
1910 Sassafras Street
Erie, PA 16502                                                  PHYSICAL THERAPY: exercises and equipment
814-452-5231                                                    to help regain or improve physical abilities
                                                                Rehabilitation Solutions (SVHC)
Priority Care                                                   Erie: 1910 Sassafras Street
3010 West Lake Road                                                    Erie, PA
Erie, PA 16505                                                         814-452-5231
814-833-2385                                                    Millcreek: 3740 Sterrettania Road
                                                                              Erie, PA
                                                                              814-833-7249
OPTHAMOLOGIST: eye injuries
Scott Griffith M.D.
Erie: 2640 West 38th Street                                     PODIATRY: foot injuries and disorders
       Erie, PA 16506                                           Foot & Ankle Center/Podiatry Associates
       814-835-8258                                             4402 Peach Street
North East: 41 S. Lake Street                                   Erie, PA 16509
             North East, PA                                     814-864-4874
             814-725-3304



                              For hours from 5:30PM – 7:00 AM Please contact

                                             HOSPITALS IN THE AREA
                                     St. Vincent Health Center – 232 W. 25th Street
                                        Hamot Medical Center – 201 State Street
                                   Millcreek Community Hospital – 5515 Peach Street




My signature confirms that I have received a copy of this list of health care providers, in the case of work-related injury.




________________________________                                                   _______________________________
Associate’s Name                                                                   Signature
        DRUG AND/OR ALCOHOL TESTING
               CONSENT FORM
                                 EMPLOYEE AGREEMENT AND CONSENT TO
                                       DRUG AND/OR ALCOHOL TESTING

I hereby agree, upon a request made under the drug/alcohol testing policy of ____________________ (the
Company), to submit to a drug or alcohol test and to furnish a sample of my urine, breath, and/or blood for
analysis. I understand and agree that if I at any time refuse to submit to a drug or alcohol test under company
policy, or if I otherwise fail to cooperate with the testing procedures, I will be subject to immediate termination. I
further authorize and give full permission to have the Company and/or its company physician send the specimen
or specimens so collected to a laboratory for a screening test for the presence of any prohibited substances
under the policy, and for the laboratory or other testing facility to release any and all documentation relating to
such test to the Company and/or to any governmental entity involved in a legal proceeding or investigation
connected with the test. Finally, I authorize the Company to disclose any documentation relating to such test to
any governmental entity involved in a legal proceeding or investigation connected with the test.

I understand that only duly-authorized Company officers, employees, and agents will have access to information
furnished or obtained in connection with the test; that they will maintain and protect the confidentiality of such
information to the greatest extent possible; and that they will share such information only to the extent necessary
to make employment decisions and to respond to inquiries or notices from government entities.

I will hold harmless the Company, its company physician, and any testing laboratory the Company might use,
meaning that I will not sue or hold responsible such parties for any alleged harm to me that might result from
such testing, including loss of employment or any other kind of adverse job action that might arise as a result of
the drug or alcohol test, even if a Company or laboratory representative makes an error in the administration or
analysis of the test or the reporting of the results. I will further hold harmless the Company, its company
physician, and any testing laboratory the Company might use for any alleged harm to me that might result from
the release or use of information or documentation relating to the drug or alcohol test, as long as the release or
use of the information is within the scope of this policy and the procedures as explained in the paragraph above.

This policy and authorization have been explained to me in a language I understand, and I have been told that if
I have any questions about the test or the policy, they will be answered.

I UNDERSTAND THAT THE COMPANY WILL REQUIRE A DRUG SCREEN AND/OR ALCOHOL TEST
UNDER THIS POLICY WHENEVER I AM INVOLVED IN AN ON-THE-JOB ACCIDENT OR INJURY UNDER
CIRCUMSTANCES THAT SUGGEST POSSIBLE INVOLVEMENT OR INFLUENCE OF DRUGS OR ALCOHOL
IN THE ACCIDENT OR INJURY EVENT, AND I AGREE TO SUBMIT TO ANY SUCH TEST.


__________________________________ __________________
Signature of Employee                      Date

__________________________________
Employee's Name - Printed

__________________________________ __________________
Company Representative                      Date


Employee completed drug screening on _____________


              Positive                                                        Negative
                         Mosaico Background Check
Name: ________________________________________________________________________

Maiden or other name(s) in any and all other records of birth or records of residence:

______________________________________________________________________________

Address: ______________________________________________________________________

City: ____________________________________ State: ________ Zip: ____________________

Date of Birth: ____/____/______ Place of Birth: _______________________________________

Social Security Number: __________________________________________________________

Gender: [__] Male [__] Female                                          Race: ____________________

Drivers License Number: ___________________________________________ State: _________

Do you have a Photo ID? [__] Yes [__] No

Home Phone: ____________________________ Cell Phone: ____________________________

Email: ________________________________________________________________________

Emergency Contact: _____________________________________________________________

Emergency Contact Phone Number: ________________________________________________

NOTE: THE FOLLOWING IS TO BE USED FOR CRIMINAL HISTORY CHECKS ONLY AND
NOT TO BE APART OF THE PERSONNEL FILE

References – Name                                                   Phone Number

   1. ________________________________________________________________________

   2. ________________________________________________________________________

   3. ________________________________________________________________________
I, _____________________________________, am an applicant for employment
work with Mosaico Employment Services (“Mosaico”) and have been advised that as a part of the
application process, Mosaico conducts a criminal history background check. I do hereby consent to
Mosaico to use any information that is provided in this application to perform a criminal history
check. Mosaico has informed me that I have the right to review and challenge any negative
information that would adversely impact a decision to offer volunteer / employment work. In
addition, I have been informed that I will have a reasonable opportunity to clear up any mistaken
information reported within a reasonable time frame established within the sole discretion of
Mosaico. Under the Fair Credit Reporting Act, I have been advised that upon request I will be
provided the name, address and telephone number of the reporting agency as well as the nature,
substance and source of all information.
The following are my responses to questions about my criminal history (if any):
   1. Have you ever been convicted or plead guilty before a court for any federal, state or
       municipal criminal offense? (Excluding minor traffic misdemeanors).
       [__] Yes [__] No
       If yes, please provide the details below:
       State: _________ County: __________________ Date of Offense: ____/____/______
       Details of Conviction: ______________________________________________________
   2. Have you ever received deferred adjudication or similar disposition for any federal, state or
       municipal offense?
       [__] Yes [__] No
       If yes, please provide the details below:
       State: _________ County: __________________ Date of Offense: ____/____/______
       Details of Conviction: ______________________________________________________
   3. Have you ever received probation or community supervision for any federal, state or
       municipal offense?
       If yes, please provide the details below:
       State: _________ County: __________________ Date of Offense: ____/____/______
       Details of Conviction: ______________________________________________________
   4. Have you ever been convicted of any criminal offense in a country outside of the jurisdiction
       of the United States?
       If yes, please provide the details below:
       State: _________ County: __________________ Date of Offense: ____/____/______
       Details of Conviction: ______________________________________________________
   5. As of the date of this consent form, do you have any pending charges against you?
       If yes, please provide the details below:
       State: _________ County: __________________ Date of Offense: ____/____/______
       Details of Conviction: ______________________________________________________
Please list all counties and states of residence since the age of eighteen:
City / Town                    County                  State                   Country
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
I hereby certify that all the information that is provided in this consent form is true, correct and
complete. All offers of employment are contingent upon the applicant’s successful completion, as
determined by the employer’s sole discretion, of this criminal history / background check.




______________________________________________________________________________
Signature of the Applicant

Authorized Person Requesting a Background Check:

Print Name: ____________________________________________________________________

Signature: _____________________________________________________________________

				
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