Employment Application Cover Sheet Diversified Industrial Services is committed to providing equal opportunity for all individuals who are seeking employment We are d

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Employment Application Cover Sheet Diversified Industrial Services is committed to providing equal opportunity for all individuals who are seeking employment We are d Powered By Docstoc
					                             Employment Application Cover Sheet

Diversified Industrial Services is committed to providing equal opportunity for all individuals who are
seeking employment. We are dedicated to a policy of non-discrimination in employment on any basis
including race, color, religion, creed, national origin, sex, age, marital status, disabled veteran, Vietnam-
era veteran, disability or sexual orientation. the objective of Diversified Industrial Services' hiring
procedure is to select the most qualified individual for the job.

An applicant who needs reasonable accommodation to assist in any step of the hiring process should
contact the Human Resources Office @ (425) 355-1253. Please E mail completed application to the
following address.shamilton@divind.com or fax to (425) 355-1261.

In submitting this application for employment I understand that Diversified Industrial Services will
investigate the information that I provide. If you are selected for an interview then you will need to
provide Diversified Industrial Services with a release and waiver form so that we may obtain a
background check and a drug test. All drug test data will be maintained as a confidential record.

I understand that I also must complete an I-9 form and provide legal documents showing I am
authorized to work in the United States. If you report false, inaccurate or misleading information, we
will reject your application or terminate your employment if we discover such information after the date
of hiring.

I understand that federal law imposes imprisonment and/or fines upon any person who makes a false
statement, uses a document issued to someone else, or uses a counterfeit, altered, forged or falsely made
document to obtain employment.

I have read and understand all of the instructions and acknowledgements set forth above. My signature
represents that I will comply and that I understand the consequences if I do not comply.




                        Applicant's Printed Name




                          Applicant's Signature                                            Date
                                                                                              Revised 06/30/2008
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Employment Application


Position Applied for:                                                                               Desired Wage:

APPLICANT INFORMATION
Last Name                                              First Name                                              M. I.        Date


Street Address                                                                                                              Apartment/Unit #


City                                                                State                                                   Zip Code


Home Phone                                Cell/Contact Phone                       E-Mail Address



Are you a citizen of the United States?    Yes   q      No     q      If no, are you authorized to work in the U.S.?         Yes     q       No   q
Have you ever worked for this company?     Yes   q      No     q      If so, when?

Have you ever been convicted of a crime? Yes     q      No     q      If yes, explain.

How did you hear about us?


EDUCATION
High School                                                         Address


From                         To
                                                               Did you graduate?     Yes   q        No   q     Degree

College                                                             Address


From                         To
                                                               Did you graduate?     Yes   q        No   q     Degree

Other                                                               Address


From                         To
                                                               Did you graduate?     Yes   q        No   q     Degree


REFERENCES (Please list three professional references)
Full Name                                                                                       Relationship/Title


Company                                                                                                        Phone (include area code)


Address


Full Name                                                                                       Relationship/Title


Company                                                                                                        Phone (include area code)


Address


Full Name                                                                                       Relationship/Title


Company                                                                                                        Phone (include area code)


Address




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PREVIOUS EMPLOYMENT
Company                                                                                                             Phone (include area code)


Street Address                                                                                                      Supervisor


Job Title                                                                                             Starting Salary              Ending Salary
                                                                                                      $                            $
Responsibilities


From                         To                           Reason for Leaving



May we contact your previous supervisor for a reference?                  Yes    q       No    q
Company                                                                                                             Phone (include area code)


Street Address                                                                                                      Supervisor


Job Title                                                                                             Starting Salary              Ending Salary
                                                                                                      $                            $
Responsibilities


From                         To                           Reason for Leaving



May we contact your previous supervisor for a reference?                  Yes    q       No    q
Company                                                                                                             Phone (include area code)


Street Address                                                                                                      Supervisor


Job Title                                                                                             Starting Salary              Ending Salary
                                                                                                      $                            $
Responsibilities


From                         To                           Reason for Leaving



May we contact your previous supervisor for a reference?                  Yes    q       No    q
MILITARY SERVICE
Branch                                                                                                From                         To



Rank at Discharge                                                                      Type of Discharge

If other than honorable, explain:

DRUG TEST
Would you be willing to take a drug test?                  Yes    q       No    q      Diversified Industrial Services is a drug-free environment.

DISCLAIMER AND SIGNATURE
I certify that my answers are true and complete to the best of my knowledge. I authorize Diversified Industrial Services to run a background investigation if I
am being seriously considered for employment. If this application leads to employment, I understand that false or misleading information in my application
or interview may result in my release.
Signature                                                                                                           Date




   4583d9cc-78a4-4853-838e-a1ad241ad5a8.xls                             Page 3 of 6                                                     Revised 06/30/2008
                     Affirmative Action Information Form

              COMPLETION OF INFORMATION BELOW IS VOLUNTARY


Diversified Industrial Services is an equal opportunity employer, dedicated to a policy
of non-discrimination in employment including race, color, creed, national origin, sex,
age, marital status, disabled veteran, Vietnam-era veteran, disability or sexual
orientation. Consistent with the American with Disabilities Act, applicants may request
accommodations needed to participate in the application process.

* This form is to be completed by applicant on a VOLUNTARY BASIS.


* The information on this form is not to be used for interview purposes.


* This form is to be filed separately from the application form(s).


      q     I volunteer to provide the following information          q     I DO NOT wish to participate



Name:                                                                          Date:


Position(s) being applied for:


Referral Source:

      q     Male                                  q    Native American Indian
      q     Female                                q    Asian / South Sea Islander
                                                  q    Black
      q     Vietnam-era veteran                   q    Hispanic
      q     Disabled veteran                      q    White (not of Hispanic origin)
      q     Disabled                              q    Other
                                                        (please specify):

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                   Pre-Employment Drug Testing Consent Form


Applicant's Printed Name




Social Security Number



I understand that all applicants who are being considered for employment with Diversified Industrial
Services are required, as a condition of employment, to take a drug-screening test. I understand that any
applicant who refuses to take, alters, tampers with or contaminates any drug test will be dropped from
further employment consideration.


I hereby consent for Diversified Industrial Services or its agents to collect a urine specimen and to conduct
urinalysis testing to determine the presence of drugs or controlled substances. I authorize release of my test
results to the appropriate representative of Diversified Industrial Services.

I understand that any candidate who fails a drug test will be dropped from further employment consideration
and may not re-apply for employment for at least 6 months.




                     Applicant's Signature                                            Date

Please complete section below:
  Subject Information

Applicant's Name                                         Social Security Number                  Date of Birth




Alias/Maiden Name                               Sex             Race              Drivers Lic # / State




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           EMPLOYER REFERENCE RELEASE


I, ________________________________________, release all former employers listed on any
application and/or resumes from any and all liabilities in giving any references on my previous work
history. Information may include job performance, duties performed, attendance practices or any other
information that a former employer may feel helpful to Diversified Industrial Services in efforts to hire a
qualified person.




                 Applicant's Printed Name




                    Applicant's Signature                                     Date




                                                                                            Revised 06/30/2008
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Description: Employment Application Marital Status document sample