HYS-JC Employment Application Form

Potomac Job Corps - Application for Employment

All statements made by applicants for employment on this application form will be checked for accuracy. We offer equal employment opportunities to all persons without discrimination on the basis of race, color, religion, age, sex, national origin, citizenship status, physical or mental disability, or past, present, or future service in the Uniformed Services of the U.S., or any other legally protected status. The use of this form does not mean there are positions open and does not obligate us in any way. This form uses 256-bit SSL encryption to protect your information during submission.
Name:*

First NameLast Name
Phone Number:*

Area CodePhone Number
E-mail Address:*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Verify Social Security No.*
Can you produce documented proof of your eligibility for employment in the U.S.? (Driver's License, Social Security Card, INS Documents, etc.)

YesNo
Position(s) applied to
How soon can you report to work?
Rate of pay expected
Type of employment desired

Full-timePart-TimeTemporary
What days and hours, if part-time?

Education

	Name	Major	Year Completed	Degree Earned
GED
High School
College
Post Graduate

How were you referred to us?

Walk-InEmployee ReferralNewspaper AdCollege RecruitmentOnline SearchOther (please specify)
Other:

References

Please list two (2) references that are familiar with your work life.
Reference 1
Name:*

First NameLast Name
Phone Number*

Area CodePhone Number
Years Known:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reference 2
Name:*

First NameLast Name
Phone Number*

Area CodePhone Number
Years Known:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reference 3
Name:*

First NameLast Name
Phone Number*

Area CodePhone Number
Years Known:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Prior Work Record (Start with most recent/present employer and complete in full)
1. Name and Address of Most Recent Employer
Job Title/Duties
Supervisor Name and Phone Number
May we contact?

YesNo
Date HiredDate Left
Starting RateLast Rate
2. Name and Address of Most Recent Employer
Job Title/Duties
Supervisor Name and Phone Number
May we contact?

YesNo
Date HiredDate Left
Starting RateLast Rate
3. Name and Address of Most Recent Employer
Job Title/Duties
Supervisor Name and Phone Number
May we contact?

YesNo
Date HiredDate Left
Starting RateLast Rate
Please provide any additional information such as special skills, training, experience, equipment operation, or other qualificationsyou feel will be helpful to us in considering your application
Upload Resume:

Upload a File

Cancelof
Job Applicant’s Agreement and Certification
“I certify that the information given by me in this application is true in all respects, and I agree that if the information given is found to be false in any way, it shall be considered sufficient cause for denial of employment or discharge. I authorize the use of any information in this application to verify my statements, and I authorize past employers, all references, and any other persons to answer all questions asked concerning my ability, character, reputation, and previous employment record. I release all such persons from any liability or damages on account of having furnished such information.”

“I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between the company and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon the company unless made in writing. If an employment relationship is established, I understand that I have the right to terminate my employment at any time and that the company retains the same right.”

“If I am offered employment, I agree to submit to a physical examination whenever requested, and I understand my becoming employed and/or my continued employment are subject to the results of any physical examination related to my job duties in accordance with company policies and procedures.”

“I understand that I will be required to take a drug test. I understand that I will be required to sign a drug free statement."

“I understand that if employed, policies, and rules which are issued are not conditions of employment and that the employer may revise policies or procedures, in whole or in part, at any time.”

"I understand that this application will be kept on file for six months from the date completed, after which time I would have to
reapply in accordance with established company procedures.”
I agree

Voluntary Self–Identification of Disability Form
Why are you being asked to complete this form?

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities.[i] To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

How do I know if I have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

Disabilities include, but are not limited to:

·   Blindness
·   Autism
·   Bipolar disorder
·   Post-traumatic stress disorder (PTSD)
·   Deafness
·   Cerebral palsy
·   Major depression
·   Obsessive compulsive disorder
·   Cancer
·   HIV/AIDS
·   Multiple sclerosis (MS)
·   Impairments requiring the use of a wheelchair
·   Diabetes

·   Epilepsy
·   Schizophrenia

·   Muscular dystrophy
·   Missing limbs or partially missing limbs
·   Intellectual disability (previously called mental retardation)

[i] Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.
Please check one of the boxes

YES, I HAVE A DISABILITY (or previously had a disability)NO, I DON’T HAVE A DISABILITYI DON’T WISH TO ANSWER
Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.
[1] Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.
Should be Empty:

Potomac Job Corps - Application for Employment

Background Check Information

Voluntary Identification Form

Voluntary Self–Identification of Disability Form