Form 6.2.1.FR
EMPLOYMENT APPLICATION
We consider applicants for all positions without regard to race, color, religion, creed, sex, national origin, age, disability, sexual orientation, gender identity, marital or veteran status, or any other legally protected status. PERSONAL INFORMATION
Last Name:________________________________________________ First Name: _____________________________________ MI:____ Street Address: __________________________________________City:___________________________ State: ______ Zip:___________ Telephone Number: _____________________ Cell Ph.#: _______________________ Email:_____________________________________ Position Applied For: _________________________________________________________ Starting Salary Desired: $________________ Note to Applicant: DO NOT ANSWER THE QUESTION BELOW UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING: Can you perform the essential functions of the job for which you are applying, either with or without a reasonable accommodation? Yes ☐ No☐ Have you ever worked for us? Yes ☐ No ☐ If so, when? _____________________________Are you at least 18 years of age? Yes ☐ No ☐ Are you available to work: Full Time ☐ Part Time ☐ If you are under 18 years of age, can you provide a work permit? Yes ☐ No ☐ If no, please explain:________________________________________________________________________________________________ Have you been convicted of a felony within the last 7 years? Yes ☐ No ☐ (Conviction will not be an absolute bar to employment). If yes, please explain: ______________________________________________________________________________________________ Are you authorized to work in the United States? Yes☐ No ☐ (Proof of identity and employment authorization will be required if hired.) EMPLOYMENT EXPERIENCE List last 3 employers, starting with the most recent. Company Name: ____________________________________ Start Date: ___________________ End Date: ________________ Address: _____________________________________________ Job Title:_______________________________________________ City_______________________ST:_______ ZIP:_____________ Supervisor Name:________________________________________ Phone Number: ______________________________________ Starting Pay $ ______________ Ending Pay $ _________________ Reason For Leaving:____________________________________ May we contact this employer? Yes ☐ No ☐ Job Duties: _______________________________________________________________________________________________________ ________________________________________________________________________________________________________________ Company Name: ____________________________________ Start Date: ___________________ End Date: ________________ Address: _____________________________________________ Job Title:_______________________________________________ City_______________________ST:_______ ZIP:_____________ Supervisor Name:________________________________________ Phone Number: ______________________________________ Starting Pay $ ______________ Ending Pay $ _________________ Reason For Leaving:____________________________________ May we contact this employer? Yes ☐ No ☐ Job Duties: _______________________________________________________________________________________________________ ________________________________________________________________________________________________________________ Company Name: ____________________________________ Start Date: ___________________ End Date: ________________ Address: _____________________________________________ Job Title:_______________________________________________ City_______________________ST:_______ ZIP:_____________ Supervisor Name:________________________________________ Phone Number: ______________________________________ Starting Pay $ ______________ Ending Pay $ _________________ Reason For Leaving:____________________________________ May we contact this employer? Yes ☐ No ☐ Job Duties: _______________________________________________________________________________________________________ ________________________________________________________________________________________________________________ Any Military Experience? Yes ☐ No ☐ Explain:____________________________________________________________________________ EDUCATION EDUCATION SCHOOL NAME MAJOR GPA WHAT DEGREE EARNED High School College / Technical School Graduate School Other (Specify) REFERENCES Please indicate 3 references for us to contact. Name: ________________________________________ # Yrs. Known: ___________ Relationship:_______________________________ Address: ___________________________________ Work Phone: _________________________ Phone: __________________________ City:_________________________________ST:______ZIP:___________ Email:_____________________________________________ Name: ________________________________________ # Yrs. Known: ___________ Relationship:_______________________________ Address: ___________________________________ Work Phone: _________________________ Phone: __________________________ City:_________________________________ST:______ZIP:___________ Email:_____________________________________________ Name: ________________________________________ # Yrs. Known: ___________ Relationship:_______________________________ Address: ___________________________________ Work Phone: _________________________ Phone: __________________________ City:_________________________________ST:______ZIP:___________ Email:_____________________________________________ Referral Source ☐ Advertisement – Where_________________________ ☐ Friend ☐ Relative ☐ Walk-­‐In ☐ Web-­‐Site ☐ Other ___________-­‐
_________ Certification & Release As an applicant for employment with Van Beek Natural Science, LLC, I understand the following: Any misrepresentation or falsification of information or significant omissions will be cause for rejection of my application or, in the event I am hired before such misrepresentation, falsification or omission is discovered, for subsequent discipline up to and including the termination of my employment. I certify that the information contained herein is correct to the best of my knowledge. I understand that any offer of employment may be contingent upon my passing a required physical examination to determine my physical ability to perform the job. If I am hired, I will be an employee “at will.” My employment is not guaranteed for any term and my employment and compensation may be terminated by Van Beek Natural Science, LLC or myself at any time and for any reason. I hereby consent to having Van Beek Natural Science, LLC contact anyone that it deems appropriate to investigate or verify any information I have given, or to discuss my background, past performance, character, reputation or suitability for employment. I hereby authorize my former employers(s), reference(s), and any other individual or organization to provide information solicited by Van Beek Natural Science, LLC, and I hereby release and discharge any person or organization so contacted and Van Beek Natural Science, LLC from any liability of any kind or nature whatsoever arising from providing or obtaining this information. Signature: _________________________________________________________ Date: ___________________________________ Note: Application not valid unless signed. Revised Date: 8-­‐15-­‐13 Origin Date: 9-­‐18-­‐06 Van Beek Natural Science, LLC, 3689 460th Street, Orange City, IA 51041 Ph: 712-­‐737-­‐2958; Toll Free: 800-­‐346-­‐5311; Fax: 712-­‐737-­‐2878 www.vanbeeknaturalscience.com