GOODMAN HARDWARE & GLASS CO.

APPLICATION FOR EMPLOYMENT

Applicant Information

Last Name / First / M.I. / Date
Street Address / Apartment/Unit #
City / State / ZIP
Phone / E-mail Address
Date Available / Position Applied for
Are you a citizen of the United States? / YES / NO / If no, are you authorized to work in the U.S.? / YES / NO
Have you ever worked for this company? / YES / NO / If so, when?
Have you ever been convicted of a crime? / YES / NO / If yes, explain
Have you ever held a security clearance? / YES / NO / If yes, what level?

Education

High School / Address
From / To / Did you graduate? / YES / NO / Degree
College / Address
From / To / Did you graduate? / YES / NO / Degree
Other / Address
From / To / Did you graduate? / YES / NO / Degree

References

Please list three professional references.
Full Name / Relationship
Company / Phone / ( )
Address
Full Name / Relationship
Company / Phone / ( )
Address
Full Name / Relationship
Company / Phone / ( )
Address

Previous Employment

Company / Phone / ( )
Address / Supervisor
Job Title / Starting Salary / $ / Ending Salary / $
Responsibilities
From / To / Reason for Leaving
May we contact your previous supervisor for a reference? / YES / NO
Company / Phone / ( )
Address / Supervisor
Job Title / Starting Salary / $ / Ending Salary / $
Responsibilities
From / To / Reason for Leaving
May we contact your previous supervisor for a reference? / YES / NO
Company / Phone / ( )
Address / Supervisor
Job Title / Starting Salary / $ / Ending Salary / $
Responsibilities
From / To / Reason for Leaving
May we contact your previous supervisor for a reference? / YES / NO

Military Service

Branch / From / To
Rank at Discharge

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.
§  If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
§  This application will remain in active status for 90 calendar days from the date of completion.
§  A driver’s license may be required depending on position.
§  This document is not intended to be nor is it a guarantee or promise of employment. Our company is an at-will employer and should you be hired, employment can be terminated at any time, with or without cause and with or without prior notice.
□ Please check here, should you need reasonable accommodations for the Interview Process.
“An Equal Opportunity Employer”
Signature / Date

VOLUNTARY APPLICANT AFFIRMATIVE ACTION INFORMATION SHEET

As an Equal Opportunity Employer, we do not discriminate on the basis of race, color, religion, sex, age, national origin, disability, genetic information, veteran status, or any other classification protected by federal, state, or local law. As a federal contractor, we comply with government regulations and affirmative action responsibilities where applicable.

Completion of this data is voluntary and will not affect your opportunity for employment. This information is solely to help us comply with government record keeping, reporting, and other legal requirements and will be kept in a confidential file separate from the Application for Employment. Thank you for your cooperation.

(PLEASE PRINT)

Position(s) applied for: ______Date: ______

Referral Source:

___ Advertisement ___ Friend ___ Relative ___ Walk-in ___ Other ______

(Please list)

Name: ______Phone: (____)______

Address: ______

Street City State Zip Code

Sex: (Check one) ___ Male ___ Female

Race/Ethnicity:

(Please check one of the descriptions below corresponding to the ethnic group with which you most identify.)

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

_____White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

_____Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa.

_____Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

_____Asian (Not Hispanic or Latino) - 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.

_____American Indian or Alaska Native (Not Hispanic or Latino) - 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 (Not Hispanic or Latino) - All persons who identify with more than one of the above five races.