APPLICATION FOR EMPLOYMENT
Applicant Information
Last NameFirst NameMiddle Initial
Street AddressCityStateZip Code
Telephone NumberAlternate Telephone NumberSocial Security Number
Position(s) Applied ForDate
Type of Employment Desired?Salary RangeDate Available To Work
Full-time Part-time Temporary Seasonal Educational Co-op
Best time to contact you at home?  May we contact you at work?
Yes No		 If you are under 18, and it is required can you furnish a work permit?
If yes, work number: Yes No
Have you submitted an application to Cardpak Inc before? Yes No
If yes, position(s) applied for and dates:		 Have you ever been employed by Cardpak Inc?
Yes No
If yes, indicate position(s) and dates:
Are you legally eligible for employment in this county? Yes No Will you relocate if required?
Yes No		 Will you travel if required?

Yes No
Are you able to meet the attendance requirement of the position? Yes No Will you work overtime if required?
Yes No
If no, please explain:
Have you ever pled "guilty" or "no contest" to, or been convicted of a crime? Yes No
If yes, please provide date(s) and details:

Answering “yes” to these question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.
Driver’s license number if driving is an essential function of the job.
Number:   
State:      
Expiration: 		How were you referred to Cardpak Inc?

Employment History
Employer Telephone Number Employer Telephone Number
Address Address
Starting Job Title/Final Job Title Starting Job Title/Final Job Title
Immediate Supervisor and Title: Immediate Supervisor and Title:
Reason for Leaving: Final Rate/Salary Reason for Leaving: Final Rate/Salary
Dates Employed May We Contact? Dates Employed May We Contact?
From
To     		 Yes No
 From
To     		 Yes No
Summarize the type of work performed and job responsibilities: Summarize the type of work performed and job responsibilities:
Employer Telephone Number Employer Telephone Number
Address Address
Starting Job Title/Final Job Title Starting Job Title/Final Job Title
Immediate Supervisor and Title: Immediate Supervisor and Title:
Reason for Leaving: Final Rate/Salary Reason for Leaving: Final Rate/Salary
Dates Employed May We Contact? Dates Employed May We Contact?
From
To     		 Yes No
 From
To     		 Yes No
Summarize the type of work performed and job responsibilities: Summarize the type of work performed and job responsibilities:

Skills And Qualifications
Summarize and special training, skills, licenses and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying.

Educational Background
School and Location Graduate Degree Earned Course of Study
High School /G.E.D:
 Yes
No
College:
 Yes
No
Advanced Degree:
 Yes
No
Other Training:
Additional Education, Training, Professional Activities or Accomplishment, Skills, or Certificate:

References
Name Telephone Years Known

Additional Information
List professional, trade, business or civic associates and any offices held.
Exclude memberships that would reveal race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran./reserve national guard or any other similarly protected status
List special accomplishments, publications, awards, etc.
Exclude memberships that would reveal race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran./reserve national guard or any other similarly protected status.
List any additional information you would like us to consider:

APPLICANT STATEMENT

I hereby authorize the potential employer to contact, obtain, and verify the accuracy of information contained in this application from all previous employers, educational institutions, and references. I also hereby release from liability the potential employer and its representatives for seeking, gathering, and using such information to make employment decisions and all other persons or organization for providing such information.

I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered.

If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either I or the employer can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law.

I understand the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law.

I understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

I represent and warrant that I have fully understand the foregoing Applicant Statement, and that I seek employment under these conditions.

By checking this box you agree to the terms above:

Voluntary Affirmative Action Information
List professional, trade, business or civic associates and any offices held.
Exclude memberships that would reveal race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran./reserve national guard or any other similarly protected status

It is the policy of Cardpak Inc, to provide equal employment opportunity to all qualified applicants and employees regardless of race, religion, color, sex, age, national origin, marital status, disability, special disabled veteran or Vietnam era veteran status.

Your completion of the information below is entirely voluntary. This information is requested solely to enable Cardpak Inc, to meet government recordkeeping, reporting and other legal obligations that apply. The information will be kept in strictest confidence and filed separately from the application. Failure to provide it will not subject you to any adverse personnel decision or action.

This information is not part of your official application for employment. It will not be used in any hiring decision.

Your cooperation is appreciated.

Position(s) Applied For: Date:
Name):
Gender: Male Female Date of Birth: Month: Day:Year:
Race/Ethnic Group:
White (not of Hispanic origin)
Black (not of Hispanic origin)
Hispanic
American Indian/Alaskan Native
Asian/Pacific Islander
Disability: Are you an individual with a physical or mental impairment which sub-stantially limits one or more of your major life activities?
Yes No
Veteran Status:
Are you a Veteran? Yes No
Disabled Veteran? Yes No
Vietnam Era Veteran? Yes No
Desert Storm/Shield Veteran? Yes No