Application New Hire Form by j0q608DU

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									           John B Campbell Family & Fitness Center of Salem County


    INSTRUCTIONS FOR COMPLETING EMPLOYMENT APPLICATION
This application package is provided to you in Microsoft Excel format for your
convenience.


To Print the entire package:
        Click "File", "Print" and select "Entire Workbook"

To Print a selected page
        Click on the tab at the bottom to address the page. Click "File", "Print" and select
        "Active Sheet(s)"

You may fill out the form in Excel by filling in the Cells marked in pale blue. Then print the
form, sign in the appropriate places and mail or fax to Mannington.
                              John B Campbell Family & Fitness Center of Salem County
                                     APPLICATION FOR EMPLOYMENT
We are an equal opportunity and affirmative action employer, dedicated to a policy of non-discrimination in
employment on the basis of race, religion, color, sex, national origin, age, martial status, citizenship, veterans' status,
physical or mental disability that does not prohibit performance of essential job functions or any other basis protected
by federal, or applicable state or local law.

PERSONAL INFORMATION
DATE:                                        SOCIAL SECURITY NUMBER:
BIRTHDAY:
NAME:
               Last                                               First                                       Middle

ADDRESS:
               Street, Road or Post Office Box


               City                                                                       State      County                 Zip Code


               Home Telephone Number                                                      Other Number
WORK INTEREST INFORMATION
How were you referred?
What job or type of job are you interested in?
Are you interested in               Full Time,                            Part Time, or              Temporary Work?
When are you available for work?                                                             Expected Wage/Salary $              per
Do you have transportation to and from work?                                          Yes                No
Can you travel?                                                                       Yes                No
Can you work overtime?                                                                Yes                No
Can you work any shift?                                                               Yes                No
GENERAL INFORMATION
Are you at least 18 years of age?                                                     Yes                No
Are you lawfully permitted to work in this country?                                   Yes                No
List your maiden name to assist us in checking your reference and background
HAVE YOU APPLIED FOR EMPLOYMENT WITH US BEFORE?                                                               Yes           No
   If yes, Date(s)
HAVE YOU WORKED FOR US?                                     Yes                  No
   If Yes, From:                                      To:                                 Position or Job Title:
   Why Did You Leave?
Have you ever been convicted of a crime?                                  Yes             No
If yes, list the conviction, its date and circumstances


Have you ever served in the Armed Forces of the United States?                                       Yes               No
   If yes, which Service                                    Date of Entrance                             Date of Discharge
   Rank at Discharge                                                             Type of Discharge
EDUCATION
     Type of School        Name of School           Major      # of years completed   Graduate? Degrees/Cert. Mo./Yr.

                                                                                              Yes
      High School                                                     1 2 3 4                 No
                                                                                              Yes           No
         College                                                      1 2 3 4                      Degree
                                                                                              Yes           No
     Post Graduate                                                    1 2 3 4                      Degree
                                                                                              Yes           No
  Technical and Other                                                                              Degree/Cert.




List any other training, education, or activities




SPECIAL KNOWLEDGE AND SKILLS

List your special knowledge and skills, and any equipment and machinery that you can operate.



REFERENCES
Please list three (3) references other than your former employers or relatives.

         Name                     Title                     Address               Telephone     Relationship to You


 1


 2


 3
EMPLOYMENT HISTORY

Please include all employment for the last ten years (List current or most recent employment first and work back in time)
       Employer                                                                      Phone
       Address
                               Street, Road or Post Office Box


                               City                                                                State       Zip Code
       Supervisor (full name):                                                             Hours Worked Per Week:
       Job title and description of your duties:
       Dates of Employment: From:                            To:               Wage/Salary:        $               Per
       Reason for leaving or why you want to change jobs:
       Employer                                                                      Phone
       Address
                               Street, Road or Post Office Box


                               City                                                                State       Zip Code
       Supervisor (full name):                                                             Hours Worked Per Week:
       Job title and description of your duties:
       Dates of Employment: From:                            To:               Wage/Salary:        $               Per
       Reason for leaving or why you want to change jobs:
       Employer                                                                        Phone
       Address
                               Street, Road or Post Office Box


                               City                                                                State       Zip Code
       Supervisor (full name):                                                             Hours Worked Per Week:
       Job title and description of your duties:
       Dates of Employment: From:                            To:               Wage/Salary:        $               Per
       Reason for leaving or why you want to change jobs:
Use a separate sheet to list additional employers, if necessary.
We may contact employers listed on this application unless you specifically exclude them. Please list any
employers you do not want us to contact and the reason for your exclusion:
Employer's Name                                         Reason




May we contact anyone at your current employer including HR or current supervisor?                             Yes          No
If no, is there a reference at your current employer we may contact confidentially?
Reference Name                                                Phone
AGREEMENTS RESTRICTING YOUR EMPLOYMENT
Have you entered into a non-solicitation, non-disclosure/confidentiality agreement or any other
agreement with a former employer that may impact your ability to do work for us?                         Yes   No
If yes, identify the Employer                                            Date of the agreement(s)
Restrictions placed upon you under the agreement(s)


Please provide us with a copy of any such agreements.
DRIVING INFORMATION
Please complete only if the position you are applying for requires that you drive a vehicle.
Driver's License(s) you possess                                          Driver's license Number
State                             Expiration Date                                Birth Date
Points, Convictions, and Accidents in the Last Five Years, if any. Please explain:




AWARDS/SPECIAL RECOGNITION
List any awards or honors (business, civic, academic) which you have received:




SUMMARY OF QUALIFICATIONS
In the space provided, describe the skills, training and skills, training and abilities that you think
qualify you for the position for which you are applying:
PLEASE REVIEW THE APPLICATION CAREFULLY. WE WILL NOT CONSIDER THIS
APPLICATION IF NOT COMPLETED IN FULL.


PLEASE READ THE FOLLOWING, AND SIGN THE APPLICATION IN THE SPACES
PROVIDED FOR BELOW. IF YOU HAVE ANY QUESTIONS, PLEASE SPEAK WITH THE
HUMAN RESOURCES REPRESENTATIVE BEFORE SIGNING.


I understand that employment by John B Campbell Family & Fitness Center of Salem County is “at will”.
This means that the employment relationship can be ended by me or by this company at any time for any
reason with or without advance notice and with or without cause. It also means that we may revise, and
make exceptions to its policies, practices, handbooks, manuals, rules, procedures, and regulations, in whole
or in part, at any time. I further understand that acceptance of an offer of employment does not create a
contractual obligation upon John B Campbell Family & Fitness Center to continue to employ me in the
future or for any specific term.

I understand that any offer of employment with John B Campbell Family & Fitness of Salem County will be
conditioned my successful completion of a physical examination. The results of these examination and tests will be
kept confidential and will not be used to discriminate against me in any way. A drug test may be administered at any
time during the selection process or employment.



If employed by John B Campbell Family & Fitness of Salem County, I agree to comply with all safety and health rules,
company policies and procedures, and local, state and federal laws pertaining to my employment.




I understand that I will be required to sign an "Agreement Regarding Confidential Information and Other Matters", as
a condition of my employment.




I have reviewed this application carefully and I hereby affirm that my statements and answers to all questions on this
application are true and correct, and that I have not knowingly withheld any fact or circumstance which, if disclosure,
would affect my application unfavorably. I understand that any misstatement or omission of fact on this application
may result my application not being considered, and if employed, may result in my immediate dismissal.


I HAVE READ AND AGREE TO THE ABOVE TERMS AND CONDITIONS.



Signature of Applicant                                                       Date
                                        INVESTIGATION AUTHORIZATION


By signing below, I hereby authorize John B Campbell Family & Fitness Center of Salem County to conduct an
investigate report and/or reference check concerning all statements contained in my application for employment, to
interview all employers, references and other individuals and institutions to obtain information and opinions about me,
and to conduct any other investigation that it deems appropriate. Such investigation may include but is not limited to
my education, employment history, character, general reputation, driving record, credit history and criminal record. In
the event that I am employed by us, I hereby authorize John B Campbell Family & Fitness Center of Salem County to
answer any inquires regarding my employment, conduct, qualification, and reasons for leaving.

I understand that I have the right to request John B Campbell Family & Fitness Center of Salem County to disclose to
me, completely and accurately, the nature and scope of the investigation. (Such a request must be made in writing to
the Human Resources Department within a reasonable time after you have completed and signed this authorization).


Address as follows:       John B Campbell Family & Fitness Center of Salem County
                                         118 Walnut Street
                                            Salem NJ 08079
                                                856-935-7789

In exchange for being considered for employment, I hereby release us, its associates, and agents, as well as any law
enforcement agency, current or former employer, educational institution, credit agency or any other individual
providing information about me to John B Campbell Family & Fitness Center of Salem County from any liability
arising from disclosure of such information which is obtained during said investigation.



Signature of Applicant                                                      Date
EMPLOYMENT HISTORY
Please include all employment for the last ten years (List most recent employment first and work back in time)

       Employer                                                            Phone
       Address
                             Street, Road or Post Office Box


                             City                                                         State     Zip Code
       Supervisor (full name):                                                     Hours Worked Per Week:
       Job title and description of your duties:
       Dates of Employment: From:                      To:              Wage/Salary:      $             Per
       Reason for leaving or why you want to change jobs:

       Employer                                                            Phone
       Address
                             Street, Road or Post Office Box


                             City                                                         State     Zip Code
       Supervisor (full name):                                                     Hours Worked Per Week:
       Job title and description of your duties:
       Dates of Employment: From:                      To:              Wage/Salary:      $             Per
       Reason for leaving or why you want to change jobs:

       Employer                                                            Phone
       Address
                             Street, Road or Post Office Box


                             City                                                         State     Zip Code
       Supervisor (full name):                                                     Hours Worked Per Week:
       Job title and description of your duties:
       Dates of Employment: From:                      To:              Wage/Salary:      $             Per
       Reason for leaving or why you want to change jobs:

       Employer                                                            Phone
       Address
                             Street, Road or Post Office Box


                             City                                                         State     Zip Code
       Supervisor (full name):                                                     Hours Worked Per Week:
       Job title and description of your duties:
       Dates of Employment: From:                      To:              Wage/Salary:      $             Per
       Reason for leaving or why you want to change jobs:
                                John B Campbell Family & Fitness Center of Salem County &
                                               Children's Space Day Care
                                            APPLICANT DATA RECORD
Employees are treated during employment without regard to race, color, religion, sex, national origin, age, martial or
veteran status, physical or mental disability, or any other legally protected status.
As an employer with an Affirmative Action Program, we comply with government regulations, including Affirmative Action
responsibilities where they apply.
The purpose for this Applicant Data Record is to comply with government record keeping, reporting, and other legal
requirements. Periodic reports are made to the government on the following information. The completion of this
Applicant Data Record is optional. If you choose to volunteer the requested information, please note that all Applicant
Data Records are kept in a confidential file and are not a part of your application for employment or personnel files.

Please note: YOUR COOPERATION IS VOLUNTARY. INCLUSION OR EXCLUSION OF ANY DATA WILL NOT
AFFECT ANY EMPLOYMENT DECISION.


                                                   VOLUNTARY SURVEY
                                                       Please type or print



                                                                                                      Date
Government agencies at times require periodic reporting on the sex, ethnicity, disability, veteran and other protected
status of applicants and employees. This data is for statistical analysis with respect to the success of our Affirmative
Action Program. SUBMISSION OF THIS INFORMATION IS VOLUNTARY.

NAME:
              Last                                  First                                 Middle

ADDRESS:
              Street, Road or Post Office Box



              City                                                                           State     Zip Code

SOCIAL SECURITY NUMBER:

POSITION APPLIED FOR:

                             PLEASE CHECK THE FOLLOWING BOXES AS APPROPRIATE

          Male                     Female

          White                    Black/African American                 Native American/Alaskan Native

          Asian                    Native Hawaiian or Other Pacific Islander

          HISPANIC OR LATINO (White race only)(a person of Mexican, Puerto Rican, Cuban, Central or South
          American, or other Spanish culture or origin, and of the White race).
          HISPANIC OR LATINO (All other races)(a person of Mexican, Puerto Rican, Cuban, Central or South
          American, or other Spanish culture or origin, and of any race other than White).




                                                            Page 5                                         Revised: 9/97
John B Campbell Family & Fitness Center of Salem County

         Consumer and/or Investigative Consumer Report Disclosure Notice
By this document, John B Campbell Family & Fitness Center, discloses to you that an investigative consumer report
(which might include information with respect to your character, general reputation, and personal characteristics) may be
obtained in connection with your employment application, and at any time during your employment.
You have the right, within a reasonable period of time after receipt of this notice, to make a written request for the nature
and scope of the investigation requested by us and a written summary of your rights under the Fair Credit Reporting Act.

Requests concerning the nature and scope of the investigation should be mailed to:
                                     Sterling Testing Systems
                                     254 West 31st Street, 6th Floor
                                     New York, NY 10001


Please sign below to signify receipt of the foregoing disclosure.



                           Applicant’s Signature                                                      Date

								
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