Employment Application Form

City Applying For? *

How were you refered to our company?

ROMER BEVERAGE COMPANY IS AN EQUAL OPPORTUNITY EMPLOYER DEDICATED TO A POLICY OF NONDISCRIMINATION IN EMPLOYMENT UPON ANY BASIS, INCLUDING RACE, COLOR, CREED, RELIGION, AGE,
SEX, NATIONAL ORIGIN, ANCESTRY, SEXUAL ORIENTATION, MARITAL STATUS, MILITARY STATUS OR THE PRESENCE OF ANY PHYSICAL OR MENTAL MEDICAL CONDITION OR DISABILITY. IN READING OR ANSWERING THE
FOLLOWING QUESTIONS, PLEASE KEEP IN MIND THAT NONE OF THE QUESTIONS ARE INTENDED TO IMPLY ANY LIMITATIONS, ILLEGAL PREFERENCES, OR DISCRIMINATION BASED UPON ANY NON-JOB-RELATED
INFORMATION. THIS APPLICATION WILL BE GIVEN COMPLETE CONSIDERATION, BUT ITS RECEIPT DOES NOT IMPLY THAT THE APPLICANT WILL BE EMPLOYED.

Are you 21 years of age or older?*

Full Name*

First NameMiddle NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

E-mail

Are You a U.S. Citizen?

YesNo

Social Security Number

Position Applying For*

Date You Can Start*

MonthDayYear

Salary Desired*

Have You Applied Here Before?*

YesNo

If So When?*

Have You Worked Here Before?*

YesNo

If So When?*

Have You Ever Been Convicted Of a Felony?*

YesNo

If So When?*

Will you Accept Night or Shift Work?*

YesNo

Choose all that apply

Attended High SchoolAttended CollegeAttended Graduate SchoolAttended Trade School

High School*

Name of High School Attended

Number of Years Attended*

Graduated?*

Yes

College*

Name of College/University Attended

Number of Years Attended*

Graduated?*

Yes

Area of Study/Degree*

Graduate School*

Name of Graduate School Attended

Number of Years Attended*

Graduated?*

Yes

Area of Study/Degree*

Trade School/Other*

Name of Trade/Technical/Other School Attended

Number of Years Attended*

Graduated?*

Yes

Area of Study/Degree*

Have you served in the U.S. Armed Forces?*

YesNo

If yes, what branch?*

From:*

Date

To:*

Date

Skills

List any relevant skills

Qualifications

List any relevant certifications or qualifications

Are you currently Employed?*

YesNo

Current Employer*

Name of Current Employer or NONE if not Employed

Position*

Salary*

Reason for Leaving?*

Start Date*

MonthDayYear

May We Contact?*

YesNo

Do you have previous employers?

YesNo

How Many?*

Previous Employer #1*

Name of Previous Employer

Position*

Salary*

Reason for Leaving?*

Start Date

MonthDayYear

End Date

MonthDayYear

Previous Employer #2*

Name of Previous Employer

Position*

Salary*

Reason for Leaving?*

Start Date

MonthDayYear

End Date

MonthDayYear

Do you have References?*

YesNo

How Many?*

Reference 1*

Name of Reference

Relationship*

Years Acquainted*

Phone*

Email*

Reference 2*

Name of Reference

Relationship*

Years Acquainted*

Phone*

Email*

Reference 3*

Name of Reference

Relationship*

Years Acquainted*

Phone*

Email*

Cover Letter

Upload a File

Resume

Upload a File

BY CLICKING THE SUBMIT BUTTON, I UNDERSTAND THAT ANY UNANSWERED QUESTIONS ON THIS APPLICATION MAY CAUSE THIS APPLICATION TO BE REJECTED.
I UNDERSTAND THAT ANY FALSE OR MISLEADING STATEMENTS ON THIS APPLICATION MAY RESULT IN MY DISMISSAL.
I AGREE TO ABIDE BY ALL THE RULES OF THE COMPANY AND WILL OBEY THE ORDERS AND INSTRUCTIONS OF MY SUPERVISORS. I WILL USE AND WEAR ALL SAFETY APPLIANCES FURNISHED ME BY
THE COMPANY AND WILL BE CAREFUL IN MY WORK AND NOT EXPOSE MYSELF OR FELLOW WORKERS TO UNNECESSARY DANGERS.
I ALSO AGREE THAT ALL FORMER EMPLOYERS OR ANY OTHER PERSONS, MAY FURNISH ROMER BEVERAGE COMPANY (THE COMPANY) WITH ALL INFORMATION REGARDING THEIR
RECORD OF MY SERVICE, CHARACTER AND REASON FOR LEAVING. I HEREBY RELEASE SUCH FORMER EMPLOYERS AND PERSONS FROM ALL LIABILITY FOR PROVIDING SUCH INFORMATION.
I HEREBY ACKNOWLEDGE AND AGREE THAT IN THE EVENT I AM EMPLOYED BY THE COMPANY, MY EMPLOYMENT WITH THE COMPANY IS AND SHALL BE SOLELY ON AN "AT-WILL" BASIS. THIS MEANS
THAT THE EMPLOYMENT RELATIONSHIP MAY BE TERMINATED AT ANY TIME BY EITHER ME, UPON GIVING PROPER NOTICE, OR THE COMPANY FOR ANY REASON NOT EXPRESSLY PROHIBITED BY
LAW, OR NO REASON. I FURTHER ACKNOWLEDGE AND AGREE THAT ANY ORAL OR WRITTEN REPRESENTATIONS BY ANY EMPLOYEE OF THE COMPANY, WHICH ARE OR MAY BE CONSTRUED AS
CONTRARY, THIS "AT-WILL" RELATIONSHIP IS INVALID AND OF NO LEGAL EFFECT.

PRE-EMPLOYMENT CONSENT AND RELEASE
THE UNDERSIGNED APPLICANT HEREBY AUTHORIZES THE COMPANY TO CONDUCT THROUGH ITS DESIGNATED PHYSICIAN, MEDICAL FACILITY OR LABORATORY TESTING FACILITY A DRUG
SCREENING TEST AS A REQUIREMENT OF EMPLOYMENT.
IN APPLYING FOR EMPLOYMENT, I UNDERSTAND THAT A URINE DRUG SCREENING TEST WILL BE ADMINISTERED AS PART OF THE PRE-EMPLOYMENT PROCESS TO DETERMINE THE PRESENCE OF
CERTAIN DRUGS AND SUBSTANCES PROHIBITED BY COMPANY POLICY, SUCH AS, ILLEGAL DRUGS, CONTROLLED SUBSTANCES, MARIJUANA, MOOD OR MIND ALTERING SUBSTANCES, “LOOK ALIKE”
SUBSTANCES, DESIGNER AND SYNTHETIC DRUGS, CERTAIN INHALANTS AND UNAUTHORIZED PRESCRIPTION DRUGS. I FURTHER UNDERSTAND THAT THE PRESENCE OF ANY OF THESE DRUGS OR
SUBSTANCES WILL CAUSE MY REJECTION FROM FURTHER CONSIDERATION FOR EMPLOYMENT, AND THAT I MAY NOT REAPPLY FOR ANY POSITION AT ROMER BEVERAGE COMPANY FOR A
PERIOD OF NOT LESS THAN SIX MONTHS.
I AGREE THAT TEST RESULTS PROVIDED BY THE COMPANY APPROVED PHYSICIANS OR TESTING LABORATORIES SHALL BE CONCLUSIVE AND FINAL, AND THAT TEST RESULTS PROVIDED BY
PHYSICIANS OR TESTING LABORATORIES NOT APPROVED BY THE COMPANY WILL NOT BE ACCEPTED OR CONSIDERED VALID.
I UNDERSTAND THAT REFUSAL TO SUBMIT TO THE DRUG SCREENING TEST WILL CONSTITUTE VOLUNTARY WITHDRAWAL OF MY APPLICATION FOR EMPLOYMENT.
I FULLY UNDERSTAND THAT SHOULD I BE CONDITIONALLY PUT TO WORK BY THE COMPANY PRIOR TO THE RESULTS OF THE DRUG-SCREENING TEST BEING KNOWN, MY CONTINUED EMPLOYMENT
WITH THE COMPANY IS CONDITIONAL UPON PASSING THE URINE DRUG SCREENING TEST. IF I SHOULD TEST POSITIVE ON THE URINE DRUG SCREEN, INDICATING THE PRESENCE OF A PROHIBITED
DRUG OR SUBSTANCE, I FURTHER UNDERSTAND I WILL BE TERMINATED IMMEDIATELY.
I AUTHORIZE THE RESULTS OF THIS URINE DRUG SCREEN TEST TO BE GIVEN TO THE COMPANY OR ANY OF ITS AGENTS.
I RELEASE AND HOLD THE COMPANY DESIGNATED PHYSICIAN, TESTING LABORATORY AND MEDICAL FACILITY HARMLESS FOR RELEASE OF THIS INFORMATION. I ALSO RELEASE AND HOLD
HARMLESS COMPANY, ITS DIRECTORS, OFFICERS, STOCKHOLDERS AND EMPLOYEES FOR THE USE OF THIS INFORMATION FOR EMPLOYMENT PURPOSES.

FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT
IN ACCORDANCE WITH THE PROVISIONS OF SECTION 604(B)(2)(A) OF THE FAIR CREDIT REPORTING ACT, PUBLIC LAW 91-508, AS AMENDED BY CONSUMER CREDIT REPORTING ACT OF 1996 (TITLE
II,SUBTITLE D, CHAPTER I, OF PUBLIC LAW 104-208), YOU ARE BEING INFORMED THAT REPORTS VERIFYING YOUR PREVIOUS EMPLOYMENT, PREVIOUS DRUG AND ALCOHOL TEST RESULTS, AND
YOUR DRIVING RECORD MAY BE OBTAINED ON YOU FOR EMPLOYMENT PURPOSES. THESE REPORTS ARE REQUIRED BY SECTIONS 382.413, 391.23, AND 391.25 OF THE FEDERAL MOTOR CARRIER
SAFETY REGULATIONS.
IN ADDITION, I GIVE PERMISSION FOR THE COMPANY TO OBTAIN A COPY OF MY DEPARTMENT OF MOTOR VEHICLES DRIVING RECORD.

Employment Application Form:

Personal Information:

Employment Desired:

Education:

Skills/Qualifications:

Current Employment:

Previous Employment:

References:

Cover Letter & Resume (Optional):

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