CHMB - CHMB’s Internal Processes & Services

Employment Application

OUR COMPANY PROVIDES EQUAL EMPLOYMENT OPPORTUNITIES TO ALL EMPLOYEES AND QUALIFIED APPLICANTS FOR EMPLOYMENT WITHOUT REGRADS TO RACE, RELIGIOUS CREED, COLOR, NATIONAL ORGIN, ANCESTRY, PHYSICAL DISABILITY, MENTAL DISABILITY, MEDICAL CONDITION, MARITAL STATUS, SEX, SEXUAL ORIENTATION OR ANY OTHER PROTECTED CLASSSIFICATION.

Please fill in all fields. If a field does not apply enter not applicable or N/A.

Date:

Please indicate the position for which you are applying:

Pay range you would be willing to accept:

Personal Information

First Name:

Last Name:

MI:

Home Phone:

Street Address:

Mobile Phone:

State:

City:

Zip Code:

Message Phone:

Are you a U.S. citizen or do you have the right to work in the U.S? Yes No

Visa Status: Permanent Resident Other Visa(indicate type):

Have you ever been employed by our company? if "yes" list dates, position, department, and supervisor.
Yes No

Do you have any relatives that work for our company? if "yes" list names:
Yes No

Have you ever been convicted of a felony? If "yes" explain. If you received an acquital or the charge was reduced no explanation necessary.
Yes No

Type of work for which you are applying:
Full-time Part-time As Needed Temporary

Can you work weekends and other shifts?
Yes No
Indicate times you cannot work:

How did you hear about our company?

IF NOT APPLYING FOR JOBS REQUIRING DRIVING OR USING COMPANY VEHICLE ENTER N/A.

Do you have a driver license?
Yes No License Number:

Have your license been suspended or revoked in the past five years? If "yes" explain:
Yes No

Have you ben convicted of a moving violation within the past five years? If "yes" explain. Yes No

EDUCATION AND SKILLS

High School Attended:

City:

State:

Did you graduate:
Yes No

OTHER EDUCATIONAL INSTITUTIONS ATTENDED	FIELD OF SPECIALIZATION	DID YOU GRADUATE?	DEGREE OBTAINED?
Name:		Yes: No:	Yes: No: N/A:
Location:
Name:		Yes: No:	Yes: No: N/A:
Location:
Name:		Yes: No:	Yes: No: N/A:
Location:
Indicate licenses, certifications, and foreign languages proficiency if job-related:
Office machines, calculators, computers, and software used(indicate your typing and/or data input speed):
Please provide information about community activities, professional, trade or service organizations to which you belong, which you believe may demonstrate your job-related abilities (You may exclude those which indicate race, color, religion, sex, national orgin, age, disability or status as a Vietnam-era or disabled veteran).

PROFESSIONAL REFERENCES

List persons familiar with your professional ability who may be contacted. Don not list relatives.

Name:	Occupation:	Phone:
Street Address:	City:	State:	Zip:
Name:	Occupation:	Phone:
Street Address:	City:	State:	Zip:
Name:	Occupation:	Phone:
Street Address:	City:	State:	Zip:

EXPERIENCE

Begin with the most recent employer. This section must be completed even if you provide a resume.

Employer:	Address:			From(Mo./Yr.)	To(Mo./Yr.)
Name of Supervisor:	Supervisor Title:	Phone:	Ext:	Starting Base Pay:
Starting Position:	Current or Last Position Held:			Current Base Pay:
Description of duties:				Reason for Leaving:
				May we contact this employer? Yes No

Employer:	Address:			From(Mo./Yr.)	To(Mo./Yr.)
Name of Supervisor:	Supervisor Title:	Phone:	Ext:	Starting Base Pay:
Starting Position:	Current or Last Position Held:			Current Base Pay:
Description of duties:				Reason for Leaving:
				May we contact this employer? Yes No

Employer:	Address:			From(Mo./Yr.)	To(Mo./Yr.)
Name of Supervisor:	Supervisor Title:	Phone:	Ext:	Starting Base Pay:
Starting Position:	Current or Last Position Held:			Current Base Pay:
Description of duties:				Reason for Leaving:
				May we contact this employer? Yes No

Employer:	Address:			From(Mo./Yr.)	To(Mo./Yr.)
Name of Supervisor:	Supervisor Title:	Phone:	Ext:	Starting Base Pay:
Starting Position:	Current or Last Position Held:			Current Base Pay:
Description of duties:				Reason for Leaving:
				May we contact this employer? Yes No

THE STATMENTST BELOW ARE PART OF THE APPLICATION PROCESS PLEASE READ CAREFULLY.

I CERTIFY THAT THE ANSWERS ON THIS APPLICATION ARE TRUE AND COMPLETE. IN SUBMITTING THIS APPLICATION FOR EMPLOYMENT. I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN. I UNDERSTAND THAT ANY MISREPRESENTATION OR OMMISSION OF PERTINANT FACTS THAT WOULD OTHERWISE MAKE ME INELIGIBLE FOR CONSIDERATION, DISCOVERED NOW OR IN THE FUTURE, WILL BE SUFFICIENT CAUSE FOR CANCELLATION OF THE APPLICATION AND/OR SEPARATION FROM THE COMPANY SERVICE. IF I HAVE BEEN EMPLOYED, I HEREBY AUTHORIZE ANY PERSON OR ORGANIZATION WHOSE NAME I HAVE GIVEN AS A REFERENCE OR BY WHOM I HAVE BEEN PREVIOUSLY EMPLOYED, TO FURNISH THE COMPANY OR ITS REPRESENTATIVES, ANY INFORMATION CONCERNING ME, WITH RESPECT TO MY QUALIFICATIONS AS AN EMPLOYEE. I HEREBY RELEASE ALL SUCH PERSONS AND ORGANIZATIONS FROM ANY CLAIMS FOR DAMAGES ARISING AS A RESULT OF THE GOOD FAITH DISCLOSURE OF SUCH RECORD OR INFORMATION.

THE FAIR CREDIT REPORTING ACT REQUIRES THAT APPLICANTS KNOW THAT A ROUTINE INQUIRY MAY BE MADE WHICH WILL PROVIDE JOB-RELATED INFORMATION CONCERNING CHARACTER AND REPUTATION. UPON WRITTEN REQUEST ADDITIONAL INFORMATION AS TO THE NATURE AND SCOPE OF THE REPORT, IF ONE IS MADE, WILL BE PROVIDED.

I UNDERSTAND THAT I MAY BE REQUIRED TO SUBMIT TO PHYSICIAN EXAMINATION TO DETERMINE MY FITNESS FOR THE WORK TO BE PERFORMED.

OUR POLICY IS NOT TO EMPLOY INDIVIDUALS WHO USE ILLEGAL DRUGS OR PRESCRIPTION DRUGS WITHOUT MEDICAL PRESCRIPTION. IN ANY AMOUNT REGARDLESSS OF FREQUENCY OR OCCASION. TO ENSURE THAT THIS POLICY IS ENFORECED, I MAY BE REQUIRED TO TAKE A DRUG SCREENING TEST AFTER A CONDITIONAL OFFER OF EMPLOYMENT IS MADE AND PRIOR TO BEGINNING WORK. THIS COMPANY WILL NOT DISCLOSE INFORMATION OBTAINED THROUGH THE DRUG SCREENING TEST EXCEPT (1) WHEN SUCH INFORMATION IS NEEDED BY PERSONS INVOLVED IN THE EMPLOYMENT DECISION, AND (2) WHEN SUCH DISCLOSURE IS REQUIRED BY LAW. IF NECESSARY, I AGREE TO PROVIDE A URINE SPECIMEN WITH THE UNDERSTANDING THAT THE SPECIMEN WILL BE USED TO TEST FOR THE PRESENCE OF ILLEGAL AND DANGEROUS DRUGS. I FURTHER AGREE THAT WHILE EMPLOYED BY THIS COMPANY, I WILL CONSENT TO DRUG AND ALCOHOL TESTING IN ACCORDANCE WITH COMPANY POLICY.

IF I AM EMPLOYED, I WILL FURNISH THE REQUIRED PROFF OF CITIZENSHIP DOCUMENTS ON MY FIRST DAY OF EMPLOYMENT AND/OR TRAINING/ORIENTATION. IF I AM NOT A U.S. CITIZEN, I WILL PROVIDE DOCUMENTATION WHICH ESTABLISHES IDENTIFICATION AND EMPLOYMENT AUTHORIZATION AS PRESRIBED BY LAW.

IN CONSIDERATION OF MY EMPLOYMENT, I AGREE TO CONFORM TO THE RULES ADN REGULATIONS OF THE COMPANY AND FURTHER AGREE THAT MY EMPLOYMENT AND COMPENSATION CAN BE TERMINATED AT ANY TIME, WITH OR WITHOUT CAUSE OR NOTICE, AT THE OPTION OF EITHER THE COMPANY OR MYSELF. I UNDERSTAND THAT NO REPRESENTATIVES OF THE COMPANY , OTHER THAN THE PRESIDENT, CEO,OR OWNER HAS ANY AUTHORITY TO ENTER INTO ANY SUCH AGREEMENT CONTRARY TO THE FOREGOING. FURTHERMORE, I UNDERSTAND AND AGREE THAT ANY SUCH AGREEMENT ENTERED INTO BY THE PRESIDENT, CEO, OR OWNER WILL NOT BE ENFORECABLE UNLESS IT IS IN WRITING.

YOUR PRIVACY IS IMPORTANT TO OUR COMPANY. PLEASE DO NOT LEAVE YOUR APPLICATION WITH ANYONE NOT DIRECTLY RESPONSIBLE FOR REVIEWING THIS APPLICATION.

I CERTIFY BY ENTERING MY NAME THAT I HAVE READ, UNDERSTAND, AND AGREE TO THE TERMS AS STATED ABOVE.

APPLICANT'S SIGNATURE DATE