English Application - General Produce Co.

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English Application - General Produce Co.
APPLICATION FOR EMPLOYMENT
An Equal Opportunity/Affirmative Action Employer
PERSONAL INFORMATION
Date_____________________________________________
Name_____________________________________________________________________________________
Last
First
Middle
Present Address____________________________________________________________________________
Street
City
State
Zip
Permanent Address_________________________________________________________________________
Street
City
State
Zip
Telephone Number (________) ___________________
Are you 18 years of age or older?  Yes  No
How did you find out about General Produce/ this job opening?____________________________________
Do you have any friends or relatives working for General Produce?  Yes  No
If yes, who?:
__________________________________________________________________________________________
EMPLOYMENT DESIRED
Position :_______________________________Date Available:__________Desired Wage:________________
 Full Time
 Part Time
Specify Hours/Days:___________________________
If applying for a Warehouse/Operations position, which shifts are you available to work?
 Day
 Swing/ Night
Are you able to perform the primary functions of the job?  Yes  No. If no, please describe what
functions cannot be performed (note: General Produce Co. will consider reasonable accommodations
that may be necessary for eligible employees):
__________________________________________________________________________________________
__________________________________________________________________________________________
Dates of any previous employment with General Produce Company
From ______to______ Supervisor_____________________________________________________________
For Office Use Only
ABRA_________________ TEST NOTICE_________________ MEMO_____________________
1
EDUCATION AND TRAINING
School
Name, City, State
# Years
Graduate? Degree/Diploma
 Si
 No
High School
______________________________________________________________________________________
Vocational/
 Si
Trade/
 No
Business
______________________________________________________________________________________
 Si
 No
College/
University
______________________________________________________________________________________
FORMER EMPLOYERS
Describe all previous employment. (List most recent employer first) Use additional paper if necessary.
Dates of
employment
Name and phone
e
number of company
Rate of Pay
Position Held
Reason(s) for
Leaving
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Relevant Experience or Special Skills:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
REFERENCES
Name
Phone#
Relationship
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
NOTICE
New employees are required to produce verification of their legal right to work in the United States. If you
are offered employment, can you produce sufficient documentation of your identity and right to work in
the United States, and attest under penalty of perjury that the documents you produce are genuine and
relate to you?  Yes  No
ADDITIONAL INFORMATION
Have you ever been convicted of a felony or of any crime for which you served a jail or prison sentence?
______________
(Do not include convictions under Health and Safety Code Sections 11357(b) or (c), 11360(b), 11364,
11365, or 11550 related to marijuana, which occurred two or more years ago, or referrals to any pre-trial
or post-trial diversion program)
Are you currently awaiting trial for any criminal offense? _______
Have you ever initiated an act of violence in the workplace? ________
A “yes” answer to these questions will not necessarily disqualify you. Please explain any “yes” answer so
that individual circumstances can be considered. Use additional paper if necessary:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Prospective employees may be required to undergo the General Produce Company’s drug/alcohol
examination. The examination includes laboratory testing for a urine sample from a prospective
employee to determine the presence of certain drugs and/or alcohol in the body.
Please Note: You should not rely upon a contingent offer of employment from General Produce Company
or otherwise engage in any activity based upon a contingent offer of employment. Unless or until a final
offer of employment is made, you should not take any action which could result in financial loss if a
contingent offer is withdrawn, such as giving notice of intent to terminate current employment, selling
real estate, or incurring any other costs associated with accepting employment with General Produce
Company. No such activity should be undertaken until after medical clearance has been received and
you have received a final offer of employment from General Produce Company. Under no circumstances
should you report to work before medical clearance is received.
AGREEMENTS
I authorize the investigation of all statements contained in this application. I understand that
falsification, misrepresentation or omission of facts will result in immediate dismissal or removal of my
application from consideration. I authorize General Produce Company to secure information about my
background and experience from other employers, education institutions, references and government
agencies, and for those parties to provide information concerning my background and experience. I
release all parties from any liability arising there from.
__________
Initial
4
If General Produce Company employs me, I agree to conform to the rules and regulations of General
Produce Company. I also understand and agree that, except for employment at-will status, my wages,
hours, working conditions, job assignments and compensation are subject to change by General Produce
Company. I understand my employment can be terminated, with or without cause and with or without
notice, at any time at the option of General Produce Company or myself. I understand that, other than
the President of General Produce Company, no manager, supervisor or representative of General Produce
Company, has authority to enter into any agreement for employment for any special period of time, or to
make any agreement contrary to at-will employment. Only the President of General Produce Company
has the authority to change my at-will status, and then only in a writing expressly changing my at-will
status.
___________
Initial
My signature below certifies that I have read and understand this application, and to the best of my
knowledge, the information I provided is true and correct. My signature below also certifies that I agree
to be bound by the terms and conditions of employment stated in this application. This application
contains all the understandings and agreements between me and General Produce Company concerning
the nature of my employment, if any, by General Produce Company, and supersedes all prior and/or
contemporaneous practices, oral or written agreements, understandings, representations and promises,
express or implied, between me and General Produce Company.
____________________________________________________
Applicant Signature
___________________
Date
It is General Produce Company’s policy to fill every position without regard to
race, color, religion, creed, sex, marital status, age, national origin, ancestry,
disability, medical condition, sexual orientation or any other consideration
made unlawful by applicable federal, state, or local laws. General Produce
Company is an equal opportunity employer and selects employees on the
basis of qualifications. Please contact the President of General Produce
Company if you have any questions or complaints regarding this policy
VOLUNTARY SELF IDENTIFICATION QUESTIONNAIRE
An Affirmative Action Employer
General Produce Company is subject to certain governmental
recordkeeping and reporting requirements for the administration
of civil rights laws and regulations. In order to comply with these
laws, the employer invites all applicants to voluntarily self-identify
their race, ethnicity and gender. Submission of this information is
voluntary and refusal to provide it will not subject you to any
adverse treatment. The information will be kept confidential and
will only be used in accordance with the provisions of applicable
laws, executive orders and regulations, including those that require
the information to be summarized and reported to the federal
government for civil rights enforcement. When reported, data will
not identify any specific individual.
Name__________________________________________________
Date___________________________________________________
□Male
□Female
Please check the race/ethnicity in which you would like to be
identified:
□Asian
□Black or African American
□Hispanic or Latino
□American Indian or Alaska Native
□White
□Two or More Races
□Native Hawaiian or Other Pacific Islander
I Decline to self-identify
Voluntary Self-Identification of Disability
Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2017
Page 1 of 1
Why are you being asked to complete this form?
Because we do business with the government, we must reach out to, hire, and provide equal opportunity to
qualified people with disabilities.i To help us measure how well we are doing, we are asking you to tell us if you
have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will
choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used
against you in any way.
If you already work for us, your answer will not be used against you in any way. Because a person may
become disabled at any time, we are required to ask all of our employees to update their information every five
years. You may voluntarily self-identify as having a disability on this form without fear of any punishment
because you did not identify as having a disability earlier.
How do I know if I have a disability?
You are considered to have a disability if you have a physical or mental impairment or medical condition that
substantially limits a major life activity, or if you have a history or record of such an impairment or medical
condition.
Disabilities include, but are not limited to:
•
•
•
•
•
Blindness
Deafness
Cancer
Diabetes
Epilepsy
•
•
•
•
•
Autism
Cerebral palsy
HIV/AIDS
Schizophrenia
Muscular
dystrophy
•
•
•
•
Bipolar disorder
Major depression
Multiple sclerosis (MS)
Missing limbs or
partially missing limbs
•
•
•
•
Post-traumatic stress disorder (PTSD)
Obsessive compulsive disorder
Impairments requiring the use of a wheelchair
Intellectual disability (previously called mental
retardation)
Please check one of the boxes below:
☐
YES, I HAVE A DISABILITY (or previously had a disability)
☐
NO, I DON’T HAVE A DISABILITY
☐
I DON’T WISH TO ANSWER
__________________________
Your Name
__________________________
Your Signature
__________________
Today’s Date
Voluntary Self-Identification of Disability
Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2017
Page 2 of 10
Reasonable Accommodation Notice
Federal law requires employers to provide reasonable accommodation to qualified individuals with
disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform
your job. Examples of reasonable accommodation include making a change to the application
process or work procedures, providing documents in an alternate format, using a sign language
interpreter, or using specialized equipment.
1
Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or
the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office
of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.
PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are
required to respond to a collection of information unless such collection displays a valid OMB control
number. This survey should take about 5 minutes to complete.
Submit Application

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