Employment Application Form

Employment Application Form:

Confidential Employment Application. PORTCO, Inc. is an Equal Opportunity Employer
Personal Data:
Full Name*

First NameMiddle NameLast Name
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState

Zip Code
E-mail
Are you eligible for employment in the United States.*

YesNo
Are you currently using an ID/DD Waiver?*

YesNo
Are You a Veteran?

YesNo
Have You Ever Been Employed by PORTCO?*

YesNo
Position Held
From

MonthDayYear
Date
To

MonthDayYear
Date
Employment Desired:
Position Applying For
Date You Can Start

MonthDayYear
Are You Willing to Work (check all that apply)

DayEveningOvernightWeekend
Were you Referred to PORTCO?

YesNo
Who Referred You?
Are You Presently Employed?

YesNo
May We Contact Your Present Employer?

YesNo
May We Contact Your Past Employers?

YesNo
Education:
High School
Name of High School Attended
High School Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Years Completed
Graduated?

YesNo
Degree/Certificate Received
College
Name of College/University Attended
College Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Number of Years Attended
Graduated?

YesNo
Degree Received
Major Field
Graduate School
Name of Graduate School Attended
Location

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Number of Years Attended
Graduated?

YesNo
Degree Received
Major Field
Trade School/Other
Name of Trade/Technical/Other School Attended
Location

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Number of Years Attended
Graduated?

YesNo
Area of Study/Degree
Skills/Qualifications:
List Any Special Skills You Possess
List any relevant skills
Qualifications
List any relevant certifications or qualifications
Work Experience
Current Employer
Name of Current Employer
Job Title Held
Start Date

MonthDayYear
End Date

MonthDayYear
Date
Reason for Leaving?
Previous Employment:
Previous Employer
Name of Previous Employer
Job Title Held
Start Date

MonthDayYear
End Date

MonthDayYear
Reason for Leaving?
Previous Employer
Name of Previous Employer
Job Title Held
Start Date

MonthDayYear
End Date

MonthDayYear
Reason for Leaving?
References:

List three persons, not related to you, who have known you for at least one year.
Reference 1
Name of Reference
Relationship
Phone
Email
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Reference 2
Name of Reference
Relationship
Phone
Email
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Reference 3
Name of Reference
Relationship
Phone
Email
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
The information contained in this application is true and correct to the best of my knowledge and is subject to inquiry by PORTCO, Inc. I understand that incorrect or misleading statements on this application would be cause for dismissal, if employed.

PORTCO, Inc. is an Equal Opportunity Employer. As required by law, we must record certain information to be made a part of our Affirmative Action Program.

Applications for employment are also invited to participate in the Affirmative Action Program by reporting their status as handicapped, disabled veteran, veteran of the Vietnam era or other minority. In extending this invitation you are also advised that: (a) applicants are under no obligation to respond, but may do so in the future if they choose; (b) responses will remain confidential within the Human Reources Department; and (c) responses will be used only for the necessary information to include in our Affirmative Action Program. We are a company that values diversity. We actively encourage women and minorities to apply. Refusal to provide this information will have no bearing on your application and will not subject you to any adverse treatment.

Please complete the information requested below. Thank you for your cooperation.
Race or Ethnic Identity*
Gender*

FemaleMalePrefer not to say
Veteran Status*

Vietnam Era VeteranSpecial Disabled VeteranOther Eligible VeteranN/A
Individual with Disabilities*

YesNoPrefer not to say
How Did You Hear of Our Opening
[**Editors note: According to 41 CFR 60-741.42, there are only two circumstances when an employer may ask a disabled applicant to self-identity on a pre-offer basis:

(1) The invitation is made when the contractor actually is undertaking affirmative action for individuals with disabilities at the pre-offer stage; or (2) The invitation is made pursuant to a Federal, state or local law requiring affirmative action for individuals with disabilities.

According to 41 CFR 60-250.42, there are only two circumstances under which an employer may ask applicants who are Special Disabled Veterans to self-identity on a pre-offer basis:

(1) The invitation is made when the contractor actually is undertaking affirmative action for special disabled veterans at the pre-offer stage; or (2) The invitation is made pursuant to a Federal, state or local law requiring affirmative action for special disabled veterans.]

EEOC RACE/ETHNIC IDENTIFICATION CATEGORIES

Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.

Caucasian/White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Black/African American: A person having origins in any of the black racial groups of Africa.

Native Hawaiian or Other Pacific Islander: A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Phillippine Islands, Thailand, and Vietnam.

American Indian or Alaska Native: A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.

Two or More Races: All persons who identify with more than one of the above five races.

Individual with Disabilities Defined as a person who (1) has a physical or mental impairment which substantially limits one or more of his or her major life activity(s), (2) has a record of such impairment(s), or (3) is regarded as having such impairment(s). For purposes of this definition, an individual with disability(s) is a substantially limited if he or she is likely to experience difficulty in securing, retaining, or advancing in employment because of the disability(s).

Special Disabled Veteran Defined as a veteran who is entitled to disability compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Veterans Administration for a disability (I) rated at 30% or more, or (II) rated at 10 or 20% in the case of a veteran who has been determined under Section 1506 to have a serious employment disability, or a person who was discharged from active duty because of a service-connected disability.

Veteran of the Vietnam Era Defined as a veteran who (a) served on active duty in the Republic of Vietnam between February 28, 1961 and May 7, 1975, or (b) served on active duty for a period of more than 180 days, any part of which occurred between August 5, 1964 and May 7, 1975, and was discharged or released therefrom with other than a dishonorable discharge, or (c) was discharged or released from active duty for a service-connected disability if any part of his or her active duty was performed between Augusst 5, 1964 and May 7, 1975.

Other Eligible Veteran Defined as any veteran who served in a "war" declared by Congress, in a campaign or on an expedition for which a campaign badge, a service medal, or an expeditionary medal has been awarded.
Employment Interest Questionnaire

What kind of job would you like to do?
What kind of job would you like to do?
Have you ever worked before?
What 3 goals would you like to achieve on your job?
What skills would you like for your job site supervisor to work with you on?
What are some likes/dislikes when it comes to a job?
Are you able to work in a fast pace work environment or would you prefer a quiet setting?

Fast PaceQuiet Setting
Would you like to work outside or in a building?

OutsideIn a Building
Are there any limitations to working such as not being able to lift more than 10 pounds, not being able to walk long distances, or not being able to stand for long periods of time?
Would you like a copy emailed?

YesNo
Should be Empty:

Employment Application Form:

Personal Data:

Employment Desired:

Education:

Skills/Qualifications:

Work Experience

Previous Employment:

References:

Employment Interest Questionnaire