Employment Application

Personal Information

Name (Last, First, MI)Street AddressCity, State, ZipHome Phone NumberWork Phone NumberCell and/or Fax NumberE-mail AddressDrivers License Number, State, Expiration

Employment Desired

Position Applied forHow did you hear about this position?Date available to workDesired hours (full time, part time, etc.)

Education

High School (Name and Address)Course of StudyTotal YearsDegree/DiplomaUndergraduateCourse of StudyTotal YearsDegree/DiplomaGraduate/ProfessionalCourse of StudyTotal YearsDegree/DiplomaOtherList any seminars, classes or other education not listed above which may help qualify you for this position.

Employment History

List below all present and past employers over the past ten years, starting with your most recent employer. Account for all periods of unemployment. It is not necessary to complete this section if you are emailing a resume additionally to hr@cornucopia-ads.orgEmployerAddressCity, State, ZipPhone numberFax numberIs this your current employer?May we contact your current employer?PositionStart (Mo/Yr)End (Mo/Yr)Essential Job Functions of Final PositionSupervisor(s)Email address of supervisor(s)Reason(s) for LeavingWhat value did you add to this company or it’s customers?

References for Employment

Reference 1NamePhone NumberE-mail addressRelationship

Reference 2NamePhone NumberE-mail addressRelationship

Reference 3NamePhone NumberE-mail addressRelationship

Reference 4NamePhone NumberE-mail addressRelationship

List any professional, trade, business or civic activities and offices held. You may exclude membership that would reveal gender, race, religion, national origin, ancestry, age, disability orany other protected status:List any languages other than English that you can speak, read or write that could be of benefit to the position applied for:SpeakReadWriteIdentify job training and experience you possess that relates to this position:Identify what skills, desires,and personality traits you possess related to this position and/or the work we do at Cornucopia:Please describe any computeror typing skills you have. List computer applications you can effectively use:Describe what you believe are the most unique features of your work history:Have you ever been employed with this company before? If Yes, when?Do you have any friends or relatives employed by this company? If Yes, please provide their name and relationship to you.If hired, can you prove U.S. citizenship or your legal right to work in the U.S.?If hired, do you have a reliable means of transportation to and from work?Do you have, or are you willing to get, a telephone with voice messaging?Are you able to perform all of the essential functions of the job for which you are applying with or without reasonable accommodation?Can you lift 50 pounds without assistance?If hired, are there any accommodations the company would need to provide sothat you can perform all those essential functions and duties of the position being applied for? If Yes, please explain in the ‘Additional Space’:If driving is a requirement of the position applied for, have you been convicted of Driving Under the Influence “(DUI)” in the last 7 years, or do you currently have any pending DUI charges?

Please read each statement closely and initial after each acknowledging your understanding Equal Employment Opportunity StatementThis company is committed to the principles of equal employment opportunity and is committed to make employment decisions based on merit. We are committed to complying with all Federal, State and local laws providing for equal employment opportunities, as well as all laws related to terms and conditions of employment. The Company desires to maintain a work environment that is free of sexual harassment and discrimination due to race, religion, color, national origin, physical or mental disability, age or any other status protected by Federal, State or local laws. The Company will make reasonable efforts to accommodate those physical or mental limitations of an otherwise qualified employee unless undue hardship would result for the company. Discrimination and Sexual Harassment Policy Statement.This Company will not tolerate any form of unlawful discrimination, including sexual harassment. Any employee who engages in unlawful discrimination or sexual harassment will be subject to appropriate discipline, up to and including termination. Prohibited sexual harassment is defined as follows: Unwelcome sexual advances, requests for sexual favors and other verbal or physical conduct of a sexual nature constitutes sexual harassment when (1) submission to such conduct ismade whether explicitly or implicitly a term or condition of an individual’s employment; (2)Submission to or action of such conduct by an individual is used as the basis for employment decisions affecting such individuals; or (3) Such conduct has the purpose or effect of unreasonably interfering with an individual’s work performance or creating an intimidating, hostile or offensive work environment.This Company will not tolerate any form of unlawful discrimination, including sexual harassment. Any employee who engages in unlawful discrimination or sexual harassment will be subject to appropriate discipline, up to and including termination. Prohibited sexual harassment is defined as follows: Unwelcome sexual advances, requests for sexual favors and other verbal or physical conduct of a sexual nature constitutes sexual harassment when (1) submission to such conduct ismade whether explicitly or implicitly a term or condition of an individual’s employment; (2)Submission to or action of such conduct by an individual is used as the basis for employment decisions affecting such individuals; or (3) Such conduct has the purpose or effect of unreasonably interfering with an individual’s work performance or creating an intimidating, hostile or offensive work environment.

Disclosure to Applicants Concerning Drug/Alcohol TestingIf you are offered a position with the Company, you may be given a drug/alcohol test as a conditionof employment. Your refusal to timely submit to a drug/alcohol test or your failure to pass such a test means you will not be employed by this company. Neither the collector of specimens nor the medical professional who reviews the test results will be a company employee. The test results will be kept confidential. The individual undergoing testing will not be directly observed while providing the specimen unless there are reasonable grounds to believe the individual may alter or substitute the specimen. Negative test results are required as a condition of employment. Complete and Accurate InformationI hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of myknowledge. I further certify that I have personally completed this application. I understand that any omission or misstatement of material fact on this application, or any other document used to secure employment, shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

Disclosure to Applicants Concerning Drug/Alcohol TestingIf offered a position with the Company, I hereby agree to any legally permitted physical, psychological, skill, drug or medical test required by the Company as a condition of employment.

At-Will EmploymentI understand and agree that if I am employed, my employment will be “at-will”, which means that the Company may terminate the employment relationship at any time, with or without cause and with or without notice. Likewise, the Company will respect my right to terminate my employment at anytime, with or without cause and with or without notice. I further understand that any prior representation, whether expressed or implied to the contrary is hereby superceded and that no promise or representation contrary to the foregoing is binding on the Company unless made in writing and signed by Cornucopia’s Executive Director and Board President.

Investigation AuthorizationI authorize investigation into all statements and references contained in this application. Said investigation may include credit, driving, criminal background, references and other background checks. By applying for this job, I also authorize post-hire investigation into my credit, driving, and criminal background.

Company ObligationI understand and agree that the Company’s acceptance of this job application does not mean that a position for which I am qualified is open (unless specifically posted) or that the company has agreed to hire me. I understand that the Company is under no obligation to hire me as the result of accepting this completed application.

I HAVE READ AND UNDERSTAND THE ABOVE POLICY STATEMENTS AND AGREE TO BE BOUND BY THEM IF EMPLOYED BY THE COMPANY.Digital Signature

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