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| Position Desired |
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| Date |
09/06/2010 |
| Last Name |
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Have you ever been convicted of a law violation (misdemeanor or felony), including moving traffic violations but excluding offences committed before your eighteen birthday, which were finally adjudicated in a Juvenile Court or under a Youth Offender Law?
Yes No
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Have you ever been dismissed or forced to resign or have you ever resigned in order to avoid being dismissed?
Yes No
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| Explain |
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If employed, will you be legally employable in the United States on the date employment is scheduled to begin?
Yes No
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| Education |
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| Skills/Certifications - List technical or specialized skills/credentials relevant to this job. Including driver's licenses (Class A-F), certifications, professional licenses, knowledge of any computer programming languages or specialized software/hardware. |
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| Operations Skills - Select the skills you possess. |
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| Office/Computer Skills - Select the skills you possess. |
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Have you ever supervised people? Yes No
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| Employment Record - List past and present employers, going back ten years. Attach additional document if needed. |
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| Describe your duties: |
| Reason for leaving: |
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| Describe your duties: |
| Reason for leaving: |
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| Describe your duties: |
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| Additional document (.doc,.docx,.rtf only) |
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| Professional References |
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| Equal Employment Opportunity Self-Disclosure Form - Optional |
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Sex/Gender Female Male
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Racial/Ethnic Heritage:
Black: not of Hispanic origin: 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, the Indian Subcontinent, or the Pacific Islands. This area includes, for example, China, Japan, Korea, the Philippine Islands and Samoa.
Native Hawaiian or Other Pacific Islander
American Indian or Alaskan Native: A person having origins in any of the original peoples of North America and who maintain cultural identification through tribal affiliation or community recognition.
Hispanic: A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture of origin, regardless of race.
White, Not of Hispanic Origin: A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.
Two or More Races:
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Vietnam Verterans Status: Yes No
For Federal reporting purposes, a Vietnam Era Veteran is defined as a veteran, any part of whose active military, naval, or air service was during the period of August 5, 1964, through May 7, 1975 who (a) served on active duty for a period of more than 180 days and was discharged or released therefrom with other than a dishonorable discharge or (b) was discharged or released from active duty because of a service-connected disability.
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Special Disabled Verterans Status: Yes No
For Federal reporting purposes, a Special Disabled Veteran is defined as a veteran who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Veterans Administration for a disability rated at 30 percent or more, or rated at 10 to 20 percent in the case of a veteran who has been determined under Section 1506 of Title 38, U.S.C., to have a serious employment handicap or a person who was discharged or released from active duty because of a service-connected disability.
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Disability/Handicap: Yes No
The Rehabilitation Act of 1973, as amended, defines a “handicapped individual” for the purposes of the program as any person who (a) has a physical or mental impairment which substantially limits one or more of such person’s major life activities; (b) has a record of such impairments; or (c) is regarded as having such impairment.
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I certify that the above statements are correct, and if employed, understand that any false information in this application, or accompanying documents, will be sufficient grounds for termination. I further agree that all policies, procedures, and regulations authorized by the company shall constitute a part of my employment. I understand if offered employment, it is contingent on the outcome of the background investigations as it relates to my suitability for the employment I seek and the outcome of my drug test. I further authorize Delta Companies Inc to check all information contained on the application and applicant materials. I hereby and forever release from any liability former employers and others who provide reference information and assessment of my work history. I further authorize education institutions and schools to provide my education credit if asked by Delta Companies Inc. |
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