PROFESSIONAL, KNOWLEDGEABLE, TRUSTWORTHY, CARING

CALLMCCAULEY.COM/EMPLOYMENT

Employment Application

This is a drug-free workplace offering equal employment opportunities.

Today's Date

Applicaliom are received and employees are hired without regard lorace, creed, color, sex, re ligion, age, nalional origin, physical or mental handicap, disability, veteran!, status, citizenship 5latu5, or any other protected classes under Slale, local or counly regulations. The receipt of this application does not mean that job openings exis t and does not obligate us in any way. We appreciate your interest in our organization.

Your Personal Information Last Name __________ _ First Name Middle Initial ____ Home Phone'---_________ _

Address __________ _ City/ State ______ Zip Code ____ Cell Phone _________ _

E-mail Address ___________________________________________ _

Preferred method of contact: 0 Home Phone o Cell Phone O E-mail o Other: _ ________ _

Your Work History And Any Employment Gaps MUST be completed even when accompanied by res .... me. Un most recent or current job first. You m .... st incl .... de any gaps in employment. with II full explanation and dales for the gap. You must also provide a complete work history for a minimum of 1S years.

Employer Dales Employed Summary of Work Performed From (Mo/Yr) I To (Mo/Yr) & Job Responsibilit ies

Address (City, Siale, Zip)

Phone

Job Title Ho .... rly Rate. Weekly Salary or Other Weekly Earnings

Starting Final

o Resigned or o Terminated State Reason: Supervisor's Name

Employer Dates Employed Summary of Work Performed From (Mo/Yr) I To (Mo/Yr) & Job Responsibilities

Address (City. State. Zip)

Phone

Job Title Hourly Rate, Weekly Salaryor Other Weekly Earnings

Slarting Final

o Resigned or o Terminated State Reason: Supervisor's Name

Employer Datestmp :oyed Summary of Work Performed From (MoIYr) I To (Mo/Yr) & Job Responsibilities

Address (City. State. Zip)

Phone

Job Title Hourly Rate. Weekly Salary or Other Weekly Earnings

Staning Final

o Resig ned or o Terminal ed State Reason: Supervisor's Name

eQualityPro Page 2 o f 6

More of Your Work History And Any Employment Gaps

Employer Dates Employed Summary of Work Performed From (MoIYr) I To (Mo!yr) & Job Responsibilities

Address (Ci ry. State, Zip)

Phone

Job Title Hourly Rail.'. Weekly Salary or Other Weekly Earnings

Starting Final

o Resigned or o Terminated Stilt{· Reason: Supef'llisor's Name

Emp oyer Dales Employed Summary of Work Performed From (MolYr) I To (Mo!Yr) & Job Responsibilities

Address (City. State, Zip)

Phone

Job Tille Hourly Rate, Weekly Salaryor Other Weekly Earnings

Starting Final

o Resigned or o Terminated State Reamn: Supervisor's Name

Tell Us About Yourself You must answer EVERY question on th is application. If a question does not apply, put N/A. Please print. What position are you applying for' _________________ _ _______________ _

What is your salary expectation? $ _ _______ _____ _ When can you start work? (Oote), _________ _

How were you referred to US? _____________ :::-__ -:---,,-___ ,---_-,.-,--_-,--_ _ ________ _ _ {If you ",ere .efeflt'd by a person, p1N5l' provide the namel

Have you completed an application here before? 0 Yes 0 No If yes, date/ location _______________ _

Have you been employed here before? 0 Yes ONa If yes, date/position/location _______________ _

Are you available to work (Check any that apply): 0 Full-time 0 Part-time 0 Temporary 0 Nights 0 Weekends

Are there any days or times during the week that you are not available to work? 0 Yes 0 No

If yes, please list the days/times you are not available to work

If necessary, can you provide proof that you are over any minimum work age requirement? 0 Yes 0 No

Are you willing to work overtime? O Ves O No Do you have steady transportation to work? 0 Yes 0 No

Can you travel, if required? O Ves O No What percentage of time? _____________ _

Are you on a layoff and subject to recall? 0 Yes 0 No May we contact your present employer? O Ves O No

Qual.,yplO Page 3 of 6

How much time have you lost from work during the pasl 12 months? ____________________ _ _

Are you now, or do you expect to be, engaged in any other business or employment while working here? 0 Yes 0 No

If yes, please explain ______________________________________ _

Are you presently an officer, employee, or employer of another business in our industry or with whom we compete? 0 Yes 0 No

If yes, please explain ______________________________________ _

Have you ever been terminated or asked to resign from a job? 0 Yes 0 No

If yes, please explain __________ _ ____ _ _ _________ _ _ __________ _

Have you ever been refused bond' 0 Yes 0 No

Why do you desire to make a change? ________________________________ _

Are you legally eligible to work in the United States 0 Yes 0 No

What three things are most important to you in a job? 1) 2) ___________ 3) ___________ _

What three adjectives best describe you? 1) ____________ _ 2) ___________ 3) ___________ _

What type of work do you most enjoy' ____ _ ____ _ ______________________ _

Whydo you want to work here? __________________________________ _

Tell Us About Your Special Skills and Qualifications List any special skills, training, experience, certi fications, or licenses that may be relevant to this position or our company ___ _

List any professional, trade, business, or civic activities or offices held that would relate to working here ____ _____ _

List any foreign languages that you fluently speak, read, and/or write t hat wou ld relate to working here _________ _

List software programs that you are proficient in ____________________________ _

Your Educational Background

Schooling Old you graduate? Years Degree Received & Name of School location Completed Major subject

High School o yes Ono orGED

Trade, Business or o yes Ono Correspondence

College Oyes Ono

Graduate School o yes Ono

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Tell Us About Your Driving Record Necessary for positions that may require use of a personal or company vehicle for work.

Do you hold a valid Driver's License? 0 Yes 0 No If yes, provide the state __________________ _

Have you been convicted of any moving violation(s) in the last 3 years? 0 Yes 0 No

If yes, give date(s) and explanation of each ______________________________ _

Tell Us About Your Past Answering yes to any of these questions is not an automatic bar to employment.

Have you ever been disciplined or terminated from any job for an act of violence, harassment, disuimination, ethical breach or then?

o Ves 0 No If yes, explain the circumstances, employer, and date ____________________ _

Have you ever been a defendant in a civil action for an intentional tort? (e-9 uwuh. b.me<y. fal~ imprisonment. infliClion of emOtional disuen. loru.ous ,merit'fenc('v.,th a bus.oness relauon~lp. del<lmal,on. invasion of privacy. !'<lud and mlSfl'prt'Wntallon. abuM! of proceu and m.I",ou~ p'ose<ut,on 01 olher~)

o Yes 0 No If yes, provide an explanation of the nature of the intentional tort, the date of the action, the locat ion, and the disposition or outcome ________________________________ _

Do you cu rrently have any criminal charges pending against you?

o Ves 0 No If yes, describe the details of the charge(s), t he date(s) of the offense(s) (month and year), your age at the time of the offense(s), and the current status of the charge(s) ______________ _______ _

Are you currently wanted by any law enforcement agency?

o Ves 0 No If yes, by what agency and for what act? _________________________ _

Tell Us About A ny Record 5 (Washington State Candidates: Jist any convictions or terms of imprisonment within the last 10years only)

Have you ever been convicted of; received a sentence for; pled nolo contendere (no contest) to; been placed on probation, fined, or entered a pretrial intervention program for; or had adjudication withheld by any judicial or quaSi-judicial body for a crime, other than a minor traffic vio lation? (Any criminal record not disclosed by you may be considered falsification of this application, which may result in revocation of your employment offer or termination of your employment. Also, in accordance with any state or federal regulations, you may be required to provide copies of any criminal records. Answering yes to this question is not an automatic bar to employment.)

O Ves O No If yes*, describe the details of the conviction or other disposition of the charge, the date of the offense (month and year), your age at the time of the offense, and your rehabilitation since the conviction a ndl or disposition of the offense ISet' bt'Iow for SPI!<,fi( inStructions .elated toyour pafli(ulal state If your state IS not listt'd. an~wf1th,s question as worded_)

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