Insource America

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Employment Application for Insource America

We consider applicants for all positions without regard to age, race, creed, color, national origin, sex, disability, marital status, or any other legally protected status pursuant to the New York State Human Rights Law and other relevant federal, state and local laws.

Position (s) Applied for
Date of Application
How Did You Learn About Us?	Advertisement Friend Internet Advertisement www. .com Employment Agency Relative Other
First and Last Name
Middle Name
Address
City
State
Zip
Telephone
Social Security Number
Best time to contact you at home is:
If you are under 18 years of age, can you provide required proof of your eligibility to work?	Yes No
Have you ever filled out an application with us before?	Yes No If yes, please give date
Have you ever been employed with us before?	Yes No If yes, please give date
Do any of your friends or relatives, other than spouse, work here?	Yes No If yes, state name, relationship, and location
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?	Yes No Proof of citizenship or immigration status will be required upon employment
Are you currently on “lay off” status and subject to recall?	Yes No
Can you travel if a job requires it?	Yes No
Have you ever been convicted of or plead guilty to a felony or misdemeanor?	Yes No

Work Experience

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities, or other protected status.

Employer

Address

Phone Number

Starting/Present Job Title

Supervisor

Reason for Leaving

May we contact?

Dates Employed

From
To

Hourly Rate/Salary

Starting
Final

Work Performed

Employer

Address

Phone Number

Starting/Present Job Title

Supervisor

Reason for Leaving

May we contact?

Dates Employed

From
To

Hourly Rate/Salary

Starting
Final

Work Performed

Employer

Address

Phone Number

Starting/Present Job Title

Supervisor

Reason for Leaving

May we contact?

Dates Employed

From
To

Hourly Rate/Salary

Starting
Final

Work Performed

Education
School	Name and Address of School	Course of Study	Years Completed	Diploma/Degree
High School
Undergraduate College
Graduate/ Professional
Other(specify)

Describe any specialized training, apprenticeship, skills, and extra-curricular activities.

Describe any job-related training received in the United States military

List professional, trade, business, or civic activities and offices held.
You may exclude membership which would reveal gender, race, religion, origin, age, ancestry, disability or other protected status

ADDITIONAL INFORMATION
Other Qualifications- Summarize special job-related skills and qualifications acquired from employment or other experience

Specialized Skills (Check Skills/Equipment Operated)

Terminal	Production/Mobile Machinery (list)	Others (list)
PC/MAC
Typing WPM

WE ARE AN EQUAL OPPORTUNITY EMPLOYER

PERSONAL/PROFESSIONAL REFERENCES
Name	Phone Number	Best Time to Call	Occupation
1.
2.
3.
*Do not include family members

GOVERNMENT ASSISTANCE PROGRAM INFORMATION
Name of your Government Assistance Program	Program Benefits	Your Assigned Rep from Suffolk County Labor Board	Your Representative’s Contact Information
1.
2.
3.

Shift Availability
Day or Night?

Note to Applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.

Are you capable of performing in a reasonable manner, with or without reasonable accommodation, the activities involved in the job or occupation for which you have applied? A review of the activities involved in such a job or occupation has been given.

Yes
No

I certify that answers given herein are true and complete. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at this time. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Employer.
I agree to the above stated terms and conditions of my employment