AN EQUAL OPPORTUNITY EMPLOYER APPLICATION FOR EMPLOYMENT GOVERNMENT EMPLOYEES' RETIREMENT SYSTEM PLEASE PRINT Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department. Position(s) applied for Date of Application Referral Source 9 Advertisement 9 Employee 9 Relative 9 Government Employee Agency 9 W alk-in 9 Private Employment Agency 9 Other Name Last First Middle Address Social Security # Street City Zip Code Mailing Address Telephone # Mobile/Beeper/Other Phone # Email Address AM If necessary, best time to call you at home is ........................................................................................ PM May we contact you at work? ...............................................................................................................................9Yes 9 No AM If yes, work number and best time to call ......................................................... PM Have you submitted an application here before? .................................................................................................9Yes 9 No If yes, give position(s) and date(s) Have you ever been employed here before? ......................................................................................................9Yes 9 No If yes, gives dates ..........................................................................................................From To Are you legally eligibile for employment in this country? ....................................................................................9Yes 9 No Date available for work ......................... W hat is your desired salary range? ..................$ Type of employment desired 9 Full-Time 9 Part-Time 9 Temporary 9 Summer 9 Educational Co-op W ill you relocate if job requires it? ................. 9 Yes 9 No W ill you travel if job requires it? ........................9Yes 9 No W ill you work overtime if required? ................................................................................................................... 9Yes 9 No If No, please explain AN EQUAL OPPORTUNITY EMPLOYER Page -2- Have you ever pled “guilty” or “no contest” to, or committed a crime ......................................................... 9 Yes 9 No If Yes, please provide date(s) and details ANSWERING “YES” TO THESE QUESTIONS DOES NOT CONSTITUTE AN AUTOMATIC BAR FROM EMPLOYMENT, FACTORS SUCH AS TO DATE OF THE OFFENSE, SERIOUSNESS AND NATURE OF THE VIOLATION, REHABILITATION AND POSITION APPLIED FOR WILL BE TAKEN INTO ACCOUNT. Have you ever been a defendant in a civil action for an international tort (e.g., a civil charge for assault, battery, intentional infliction of emotional distress, false imprisonment, wrongful death, etc.)? .................................................... 9 Yes 9 No If Yes, please provide nature of the tort and disposition of the matter (how it was resolved) Driver’s license number if driving is an essential for the position State Employment History Provide the following information of your past four employment activities, starting with the most recent. From To Employer Telephone # Starting Job Title/ Final Job Title Address Immediate Supervisor and Title Summarize the Nature of work Performed and Job Responsibilities May We Contact For Reference? 9Yes 9No 9 Later Reason for Leaving Hourly Rate/Salary Start $ Per Final $ Per What did you like most about your position? What were the things you liked least about your position? AN EQUAL OPPORTUNITY EMPLOYER Page -3- Employment History (continued) From To Employer Telephone # Starting Job Title/ Final Job Title Address Immediate Supervisor and Title Summarize the Nature of work Performed and Job Responsibilities May We Contact For Reference? 9Yes 9No 9 Later Reason for Leaving Hourly Rate/Salary Start $ Per Final $ Per What did you like most about your position? What were the things you liked least about your position? From To Employer Telephone # Starting Job Title/ Final Job Title Address Immediate Supervisor and Title Summarize the Nature of work Performed and Job Responsibilities May We Contact For Reference? 9Yes 9No 9 Later Reason for Leaving Hourly Rate/Salary Start $ Per Final $ Per What did you like most about your position? What were the things you liked least about your position? From To Employer Telephone # Starting Job Title/ Final Job Title Address Immediate Supervisor and Title Summarize the Nature of work Performed and Job Responsibilities May We Contact For Reference? 9Yes 9No 9 Later Reason for Leaving Hourly Rate/Salary Start $ Per Final $ Per What did you like most about your position? What were the things you liked least about your position? AN EQUAL OPPORTUNITY EMPLOYER Page -4 Explain any gaps in your employment, other than those due to personal illness, injury or disability. If not addressed on previous page, have you ever been fired or asked to resign from a job? .....................9Yes 9No If Yes, please explain Educational Background Number of Years Name & Location Completed Did You Graduate? Course of Study High School or GED College or University Degree Major Other (Certification) Licenses Skills and Qualifications Summarize any special training, skills, licenses and/or certificates that may assist you in performing job-related functions for the position for which you are applying. AN EQUAL OPPORTUNITY EMPLOYER Page -5- Skills and Qualifications (continued) Computer Skills (Check appropriate boxes. Include software titles and years of experience) 9 Word Processing Years: 9 Internet Years: 9 Spreadsheet Years: 9 Database Years: 9 Presentation Years: 9 Main Frame Years: 9 Email Years: 9 Other Years: Related Information To W hat job-related organizations (professional, trade, etc.) do you belong? 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. Organizations Offices Held 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. In your current or prior job, have you ever written instructions or directions to be followed by employees or customers? 9 Yes 9No 9Not Applicable If Yes, please explain: Is there any other job-related information you want us to know about you? AN EQUAL OPPORTUNITY EMPLOYER P a g e - 6 - References List names and telephone numbers of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you. Name Title Relationship to You Telephone Number of Years Known ( ) ( ) ( ) Applicant Statement I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct. I understand that any information provided by that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) cancel further consideration of this application, or (ii) immediately discharge me from the employer’s service, whenever it is discovered. I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me. I understand that the employer does not unlawfully discriminate in employment and no 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 this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to reapply and fill out a new application. If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied, oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer’s president. I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and its territories and that federal immigration laws require me to complete an I-9 Form in this regard. DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement. Signature of Applicant Date / / SIGN