TO: Applicants for Employment

TO: Applicants for Employment

RE: Applicant Information on Ethnicity, Sex, Disabled Veteran, and Vietnam Era Veteran Status.

As a federal contractor, Chesapeake Service Systems, Inc. is required to take affirmative steps to hire, train and promote qualified persons with disabilities, disabled veterans of the Vietnam Era and other protected class members.

Submitting this completed form is entirely voluntary on your part, and refusal to do so will not impact our consideration of you as an applicant or otherwise subject you to any adverse treatment.

Thank You for your cooperation and assistance.

CSSI, in compliance with Titles VI and VII of the Civil Rights Act of 1964, Sections 503 and 504 of the Rehabilitation Act of 1973 and Title I of the Americans with Disabilities Act of 1990, does not discriminate on the basis of race, color, national origin, religion, sex, marital status, or disability in any of it’s policies, procedures, or practices; nor does CSSI, in compliance with Age Discrimination in Employment Act of 1967 and Section 402 of the Vietnam Era Veterans Readjustment Act of 1974, discriminate against any employee or person seeking employment an a basis of their age or because they are disabled veterans or veterans of the Vietnam era.

In conformance with CSSI policy and pursuant to Executive Order 11246, as amended, Section 503 of the Rehabilitation Act of 1973 and Section 402 of the Vietnam Era Veterans Readjustment Act of 1974, CSSI is an affirmative action/equal opportunity employer

Providing Vocational and Related Services

An Equal Opportunity Organization

APPLICATION FOR EMPLOYMENT

PRE-EMPLOYMENT QUESTIONAIRE AN EQUAL

OPPORTUNITY EMPLOYER

PERSONAL INFORMATION

DESIRED EMPLOYMENT

Position / Date You Can Start / Salary Desired
Are You Employed Now?
Yes No / If So, May We Inquire
Of Your Present Employer? Yes No
Ever Applied To This Company Before?
Yes No / Where? / When?
Ever Worked For This Company Before?
Yes No / Where?
/ When?
Reason For Leaving?
Name Of Last Supervisor At This Company
Who Referred You to This Company?
Employment Agency Newspaper Advertisement Friend
State Employment Office College Placement Service Walk- In Other

EDUCATION

SCHOOL LEVEL / NAME AND LOCATION OF SCHOOL / NO. OF YEARS
ATTENDED / DID YOU
GRADUATE? / SUBJECTS STUDIED
Grammar School
High School
College
Trade, Business or
Correspondence
School

GENERAL

Subjects of Special Study Or Research Work
Special Training
Special Skills

FORMER EMPLOYERS

LIST BELOW LAST THREE EMPLOYERS, STARTING WITH THE MOST RECENT ONE FIRST

Name Of Present
Or Other Employer
Address / City / State / Zip Code
Starting Date / Leaving Date / Job Title
Weekly Starting Salary / Weekly Final Salary / May We Contact
Your Supervisor? Yes No
Name Of Supervisor / Title / Phone
Description Of Work
Reason For Leaving
Name Of Previous Employer
Address / City / State / Zip Code
Starting Date
/ Leaving Date / Job Title
Weekly Starting Salary / Weekly Final Salary / May We Contact
Your Supervisor Yes No
Name Of Supervisor / Title / Phone
Description Of Work
Reason For Leaving
Name Of Previous Employer
Address / City / State / Zip Code
Starting Date / Leaving Date / Job Title
Weekly Starting Salary / Weekly Final Salary / May We Contact
Your Supervisor? Yes No
Name Of Supervisor / Title / Phone
Description Of Work
Reason For Leaving

REFERENCES

Below, Give The Names Of Three Persons You Are Not Related To, Whom You Have Known At Least One Year.

NAME / ADDRESS / BUSINESS / PHONE # / YEARS
KNOWN
1
2
3

SERVICE RECORD

Branch Of Service / Discharge Date/ Rank
Have You Been Convicted Of A Felony Within The Last 5 Years? Yes No
If Yes, Explain. (Will Not Necessarily Exclude You From Consideration)

AUTHORIZATION

“I certify that the facts contained in this application are true and complete to the best of my knowledge and understand and that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise and release the company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.”

SIGNATURE: DATE: