PROVIDER1312018

Application for Employment 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 the General Manager, District Manager or Corporate Office.

Location ________________________________________________________________________________________________________

Position(s) applied for _____________________________________________________ Date of application ______ / ______ / ______

Referral Source Advertisement Employment Relative Person ______________________

Walk-in Private Employment Agency Other _______________________

Name ___________________________________________________________________________________________________________________________________________________________

AM

If necessary, best time to call you at home is

PM

May we contact you at work? Yes No

AMIf yes, work number and best time to call ( ) PM

If you are under 18 and it is required, can you furnish a work permit? Yes No

If no, please explain

Have you previously been employed by Market Broiler Restaurants or Provider Contract Food Services? Yes No

If yes provide dates ____/_____/______ - _____/_____/_____

If yes, did you provide notice of your resignation of employment from Market Broiler Restaurants or Provider Contract Food Services?

Yes No

Are you legally eligible for employment in this country? Yes No

Date available for work / / What is your desired wage / salary range? $ per

Type of employment desired Full Time Part Time Temporary Seasonal

Yes No

Yes No

Yes No

Will you relocate if job requires it?

Can you perform the functions of this job (essential and/or marginal), with/without reasonable accommodation?

Will you work overtime if required?

If no, please explain

ANSWERING “YES” TO THESE QUESTIONS DOES NOT CONSTITUTE AN AUTOMATIC BAR TO EMPLOYMENT, FACTORS SUCH AS DATE OF THE OFFENSE, SERIOUSNESS AND NATURE

OF VIOLATION, REHABILITATION AND POSITION APPLIED FOR WILL BE TAKEN INTO ACCOUNT.

AN EQUAL OPPORTUNITY EMPLOYER

LAST FIRST MIDDLE

Address____________________________________________________________________________________________________________ Social Security # _______________________

Telephone # ( )________________________ Phone Other # ( )________________________Email________________________________________________

Employment History

Provide the following information of your past and current employers, assignments or volunteer activities, starting with the most recent (use

additional sheets if necessary). Explain any gaps in employment in comments section below.

TELEPHONE #

EMPLOYER ( )

DATES EMPLOYED SUMMARIZE THE TYPE OF WORK

PERFORMED AND JOB RESPONSIBILITIES FROM

TO

ADDRESS

STARTING JOB TITLE / FINAL JOB TITLE

IMMEDIATE SUPERVISOR AND TITLE

REASON FOR LEAVING

MAY WE CONTACT FOR REFERENCE? YES NO LATER

EMPLOYER TELEPHONE #

( )

DATES EMPLOYED SUMMARIZE THE TYPE OF WORK

PERFORMED AND JOB RESPONSIBILITIES FROM

TO

ADDRESS

STARTING JOB TITLE / FINAL JOB TITLE

IMMEDIATE SUPERVISOR AND TITLE

REASON FOR LEAVING

MAY WE CONTACT FOR REFERENCE? YES NO LATER

EMPLOYER TELEPHONE #

( )

DATES EMPLOYED SUMMARIZE THE TYPE OF WORK

PERFORMED AND JOB RESPONSIBILITIES FROM

TO

ADDRESS

STARTING JOB TITLE / FINAL JOB TITLE

IMMEDIATE SUPERVISOR AND TITLE

REASON FOR LEAVING

MAY WE CONTACT FOR REFERENCE? YES NO LATER

EMPLOYER TELEPHONE #

( )

DATES EMPLOYED SUMMARIZE THE TYPE OF WORK

PERFORMED AND JOB RESPONSIBILITIES FROM

TO

ADDRESS

STARTING JOB TITLE / FINAL JOB TITLE

IMMEDIATE SUPERVISOR AND TITLE

REASON FOR LEAVING

MAY WE CONTACT FOR REFERENCE? YES NO LATER

Educational Background

A. List the last three (3) schools attended, starting with most recent. B. List number of years completed. C. Indicate degree or

diploma earned, if any. D. Grade Point Average or Class Rank. E. Major field of study. F. Minor field of study (if applicable).

A. SCHOOL B. NUMBER OF

YEARS COMPLETED

C. DEGREE

DIPLOMA

D. GPA

CLASS RANK

E. MAJOR F. MINOR

Skills and Qualifications

Summarize any 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.

References

List name and telephone number 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 TELEPHONE NUMBER OF

YEARS KNOWN

( )

( )

( )

List any additional information you would like us to consider,

Applicant Statement

I certify that all information provided in order to apply for and secure work with the employer is true, complete and correct.

I understand that any information provided by me 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 Market Broiler’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 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 this application remains current for only 30 days. At the end 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.

It is my understanding that PROVIDER CONTRACT FOOD SERVICE is an at-will employer and by understanding this it has been

explained to me that if I am hired, I understand that I am free to resign at any time, with or without cause and 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 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 / / .

For Office Use Only:

Location Schedule Updated: SHIFT(S) HIRED TO FILL: ________________________________________

Hot Schedules:

_________________________________________________________________

Employee Availability

Name___________________________ Location_________________

Date Available To Start___________ CBU Student: Y N

Desired Weekly Hours_________

Specify time frame available:

Monday Anytime NO ____________________

Tuesday Anytime NO ____________________

Wednesday Anytime NO ____________________

Thursday Anytime NO ____________________

Friday Anytime NO ____________________

Saturday Anytime NO ____________________

Sunday Anytime NO ____________________

*I understand every intention will be made to accommodate the requests outlined above, but in

some instances the staffing needs of your location will take precedence over scheduling

requests. Please indicate the reason you are unavailable.

*I am willing to work when scheduled and needed.

*If my availability changes, it is my responsibility to submit a new availability form.

Employee Signature_______________________________ Date______________

Phone Number: ___________________________________

Email Address: ___________________________________

Availability forms are to be turned into the Provider office, Yeager D123

It will take 10 days for changes to be processed.

Students must attach a copy of your class schedule.

This OrganizationParticipates in E-Verify

This employer will provide the Social Security Administration (SSA) and, if necessary, the Department of Homeland Security (DHS), with information from each new employee’s Form I-9 to confirm work authorization.

IMPORTANT: If the Government cannot confirm that you are authorized to work, this employer is required to give you written instructions and an opportunity to contact DHS and/or the SSA before taking adverse action against you, including terminating your employment.

Employers may not use E-Verify to pre-screen job applicants and may not limit or influence the choice of documents you present for use on the Form I-9.

To determine whether Form I-9 documentation is valid, this employer uses E-Verify’s photo matching tool to match the photograph appearing on some permanent resident cards, employment authorization cards, and U.S. passports with the official U.S. government photograph. E-Verify also checks data from driver’s licenses and identification cards issued by some states.

If you believe that your employer has violated its responsibilities under this program or has discriminated against you during the employment eligibility verification process based upon your national origin or citizenship status, please call the Office of Special Counsel at 800-255-7688, 800-237-2515 (TDD) or at www.justice.gov/crt/osc.

N O T I C E: Federal law requires all employers to verify the identity and employment eligibility of all persons hired to work in the United States.

E-Verify Works for Everyone For more information on E-Verify, please contact DHS:

888-897-7781

www.dhs.gov/E-VerifyThe E-Verify logo and mark are registered trademarks of Department of Homeland

Security. Commercial sale of this poster is strictly prohibited.

IF YOU HAVE THE RIGHT TO WORK, Don’t let anyone take it away.

If you have the legal right to For assistance in your own language: UEmployers cannot terminate you work in the United States, there are Phone: 1-800-255-7688 or Cbecause of E-Verify without giving laws to protect you against (202) 616-5594 you an opportunity to resolve the discrimination in the workplace. For the hearing impaired: problem. TTY 1-800-237-2515 or I You should know that – (202) 616-5525 E In most cases, employers cannot

require you to be a U.S. citizen or E-mail: osccrt@usdoj.gov In most cases, employers cannot a lawful permanent resident. deny you a job or fire you because Or write to: of your national origin or If any of these things have U.S. Department of Justice – CRT citizenship status or refuse to happened to you, contact the Office of Special Counsel – NYA accept your legally acceptable Office of Special Counsel (OSC). 950 Pennsylvania Ave., NW documents.

Washington, DC 20530 Employers cannot reject documents

because they have a future expiration date.

.S. Department of Justice ivil Rights Division

Office of Special Counsel for mmigration-Related Unfair mployment Practices

www.justice.gov/crt/about/osc