AN EQUAL OPPORTUNITY EMPLOYER

Internal Use Only: Applicant ID#:

Application for Employment

Full Name *

Phone *

Email *

Address

Street Address

City

State

Postal Code

Position(s) applied for: *

Date Applied: *

If necessary, best time to call you:

Have you ever been employed here before? (Check one) *

Yes

If 'yes' provide dates and position(s):

Is this application a request for reemployment following an extended military leave of absence from this company?

Yes

Are you legally eligible for employment in this country? *

Yes

Date available for work:

What is your desired salary range or hourly rate of pay?

Are you willing to relocate if job requires it?

Yes

Are you willing to travel if job requires it?

Yes

If they have been explained to you, are you able to meet the attendance requirements of the position?

N/A

Yes

Will you work overtime if required?

Yes

If 'No', please explain:

Are you able to perform the "essential functions" of the job for which you are applying (with or without reasonable accommodation)? This question is not designed to elicit information about an applicant's disability. Please do not provide information about the existence of a disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stage to the extent permitted by law.

Yes

Need more information about the job's "essential functions" to respond

Driver's license number required if driving may be required in the job for which you are applying (include State):

Have you ever been bonded?

Yes

Answering "yes" to the following question below does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness nature of the violation, rehabilitation and position applied for will be taken into account.

Have you ever pleaded "guilty" or "no contest" to or been convicted of a crime?

Yes

Have you ever entered into an agreement with any former employer or other party (such as a noncompetition agreement) that might, in any way, restrict your ability to work for our company?

Yes

If 'Yes', please explain:

Employment History

Starting with your most recent employer, provide the following information.

Employer 1

Employer

Starting Job Title / Final Job Title

Employer Phone Number

Employer Address

Dates Employed

Compensation (Starting)

Hourly

Salary

$ amount per year or hour (please specify)

Compensation (Final)

Hourly

Salary

Final Commission / Bonus / Other Compensation:

Immediate Supervisor

May we contact for reference?

Yes

If 'yes', Supervisor / HR Email

Why did you leave?

Commission / Bonus / Other Compensation:

Summarize the type of worked performed and job responsibilities:

What did you like most about your position?

What were the things you liked least about the position?

Employer 2

Employer

Starting Job Title / Final Job Title

Employer Phone Number

Employer Address

Dates Employed

Compensation (Starting)

Hourly

Salary

$ amount per year or hour (please specify)

Commission / Bonus / Other Compensation:

Compensation (Final)

Hourly

Salary

Final Commission / Bonus / Other Compensation:

Immediate Supervisor

May we contact for reference?

Yes

If 'yes', Supervisor / HR Email

Why did you leave?

Summarize the type of worked performed and job responsibilities:

What did you like most about your position?

What were the things you liked least about the position?

Additional Employment History

Additional work experience you would like us to review can be included here:

Upload Resume (optional):

Applicant Statement

I certify that all information I have provided in order to apply for and secure work with this employer is true, complete and correct

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state or federal law.

I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does-not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer's president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an 1-9 Form in this regard.

This Company does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding an applicant from consideration for employment on the basis of his or her sex, race, color, religion, national origin, genetic information, citizenship, age, disability, or any other protected status under applicable federal, state, or local law. This Company likewise does not tolerate harassment based on sex, race, color, religion, national origin, citizenship, genetic information, age, disability, or any other protected status. Examples of prohibited harassment include, but are not limited to, unwelcome physical contact, offensive gestures, unwelcome comments, jokes, epithets, threats, insults, name-calling, negative stereotyping, possession or display of derogatory pictures or other graphic materials, and any other words or conduct that demean, stigmatize, intimidate, or single out a person because of his/her membership in a protected category. Harassment of our employees is strictly prohibited, whether it is committed by a manager, coworker, subordinate, or non-employee (such as a vendor or customer). The Company takes all complaints of harassment seriously and all complaints will be investigated promptly and thoroughly.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer's service, whenever it is discovered.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

Signature of Applicant *

Clear

Date Signed *

This product is designed to provide accurate and authoritative information. However, it is not a substitute for legal advice and does not provide legal opinions on any specific facts or services.

The information is provided with the understanding that any person or entity involved in creating, producing or distributing this product is not liable for any damages arising out of the use or inability to use this product. You are urged to consult an attorney concerning your particular situation and any specific questions or concerns you may have.

Important note: This is approved for use by the purchaser only. This form may no be shared publicly or with third parties.

COMPLYRIGHT

INSTRUCTIONS

PLEASE READ ALL INSTRUCTIONS CAREFULLY BEFORE COMPLETING THIS FORM

Anti-Discrimination Notice. It is an unlawful employment practice for an employer to fail or refuse to hire or discharge any individual, or otherwise to discriminate against any individual with respect to that individual's terms and conditions of employment, because of such individual's race, color, religion, sex, or national origin.

Newman Technology is subject to certain nondiscrimination and affirmative action recordkeeping and reporting requirements which require Newman Technology to invite employees to voluntarily self-identify their race/ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and may only be used in accordance with the provisions of applicable federal laws, executive orders, and regulations, including those which require the information to be summarized and reported to the Federal Government for civil rights enforcement purposes.

If you choose not to self-identify your race/ethnicity at this time, the federal government requires Newman Technology to determine this information by visual survey and/or other available information.

For civil rights monitoring and enforcement purposes only, all race/ethnicity information will be collected and reported in the seven categories identified below. The definitions for each category have been established by the federal government If you choose to voluntarily self-identify, you may mark only one of the boxes presented below.

INVITATION TO SELF-IDENTIFY

PLEASE ANSWER THE FOLLOWING QUESTION

What is your gender?

Female

Male

What is your race/ethnicity? Please mark the one box that describes the race/ethnicity category with which you primarily identify.

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

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

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

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 Philippine Islands, Thailand, and Vietnam.

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

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 maintains tribal affiliation or community attachment.

Two or More Races: a person who primarily identifies with two or more of the above race/ethnicity.

Full Name as Signature: *

Date: *

FAIR CREDIT REPORTING ACT

Disclosure and Authorization to Obtain and Use Consumer Reports

Newman Technology, Inc. hereby discloses to you that a consumer report, as defined by the Fair Credit Reporting Act, may be obtained for employment purposes by it, its affiliates, representatives, or agents. The undersigned hereby authorizes the procurement of the consumer report at such times as deemed appropriate by the Company.

Full Legal Name: *

Last 4 digits of Social: *

Signature Here: *

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Application Date *

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