Job descriptions and applications

The preparation of job descriptions and applications are important tasks for a Kansas employer.  Missteps in either of these areas can subject an employer to legal liability under state and/or federal law, while carefully crafted job descriptions and applications can assist an employer in finding and hiring valuable employees.

Job descriptions

After a Kansas employer decides to fill a new position or a current position, the first step it should take is to create or revise the job description.  The job description should be a thorough listing of the duties, skills, education, training, experience, and physical attributes required in the job.

Well-developed job descriptions can provide at least the following benefits to an employer:

• an employer will have a better idea about the type of person who would perform well in the job
• an employer can use the job description to prepare and ask useful interview questions
• a job description, especially one listing the “essential functions of the job,” can help insulate the employer from claims of discrimination by a job applicant who is not hired or by an employee who is terminated.  This is particularly important for employers covered by the Americans with Disabilities Act (ADA).

There are certain statements that may be advisable for a job description to contain, including the following:

• a statement as to the employment-at-will relationship – as discussed in Chapter 2, Introduction, it is important to make sure that the job applicant understands this relationship
• a statement that the employer reserves the right to modify, interpret, or apply the job description in any way the company desires and that the job description is not a contract for employment
• if the employer is covered by the ADA, a statement that the job description does not necessarily include every duty, or every “essential duty,” of the position – language such as this helps protect an employer from discrimination claims under the ADA.

A sample job description form has been provided in this book.  It is not intended to cover every job and should be tailored, with the advice of an employment attorney, for the various jobs within the organization.

Job description

Job Title: ____________________________________________________________  
Date of this Job Description: ____________________________________________________________


Job Summary: ____________________________________________________________




ESSENTIAL FUNCTIONSof the Job (listed in order of importance):

1.

2.

3.

4.

5.


MARGINAL JOB FUNCTIONS:

1.

2.


Skills Required to Perform the Duties of the Job:

1.        

2.                    


Educational Requirements Needed to Perform the Duties of the Job:

1.        

2.        


Weight Lifting (or other physical) Requirements to Perform the Duties of the Job:

1.        

2.        


Licensing or Other Special Certifications Required:

1.        

2.        




Job Description Approved by: ____________________________________________________________


                                                                                   

Signature/Title:_____________________________________             Date:_______________________________


***THIS COMPANY RESERVES THE RIGHT TO MODIFY,
INTERPRET, OR APPLY THIS JOB DESCRIPTION IN ANY WAY THE 
COMPANY DESIRES. THIS JOB DESCRIPTION IN NO WAY IMPLIES 
THAT THESE ARE THE ONLY DUTIES, INCLUDING ESSENTIAL
DUTIES, TO BE PERFORMED BY THE EMPLOYEE OCCUPYING THIS
POSITION. THIS JOB DESCRIPTION IS NOT AN EMPLOYMENT
CONTRACT, IMPLIED OR OTHERWISE. THE COMPANY REMAINS AN
“AT-WILL” EMPLOYER.  QUALIFIED EMPLOYEES WHO REQUIRE
REASONABLE ACCOMMODATIONS TO PERFORM THE ESSENTIAL
FUNCTIONS OF THE POSITION SHOULD NOTIFY THE HUMAN
RESOURCES DIRECTOR.***

Job applications

Once a job description has been prepared, an employer can begin the process of screening qualified applicants.  The first step in the applicant screening process is preparing the employment application.  A Kansas employer should only request information in an application or an interview that is based on bona fide occupational qualifications.   Soliciting other information can subject an employer to legal liability under civil rights laws such as the Americans with Disabilities Act (ADA), the Age Discrimination in Employment Act (ADEA), Title VII of the Civil Rights Act of 1964 (Title VII), the Kansas Act Against Discrimination, and the Kansas Age Discrimination in Employment Act.  Beforesupplying an application to job applicants, an employer should consult with its employment attorney to determine whether every inquiry on the application is proper.

A Kansas employer should not request information in the application process about the following, unless the inquiry is based on a bona fide occupational qualification.  Inquiries to avoid include the following:

• race
• color
• religion
• sex
• disability
• national origin, ancestry, birthplace, or native language
• genetic information (including medical history of family members)
• age
• medical conditions
• economic status (including bankruptcy)
• children or child-rearing plans
• pregnancy or plans to become pregnant
• name or address of relatives
• workers’ compensation claims
• military service
• veteran’s status
• garnishments
• arrests and convictions (unless accompanied by a statement that an arrest or conviction will not necessarily preclude employment)
• labor union activity.

As with the job description, there are certain statements that may be advisable to include.  These statements include the following:

• An Equal Employment Opportunity statement, such as the following:

“We consider applicants for all positions without regard to race, color, religion, national origin or ancestry, sex, age (40+), disability, veteran status, or any other legally protected status under local, state, or federal law.”

• A statement such as this shows that the employer takes seriously its commitment not to discriminate in its hiring practices against legally protected classes of people, and it also helps remind management, as they review applications, not to discriminate.
• A statement as to the employment-at-will relationship, such as the following:

“We are an at-will, equal opportunity employer.”

• As discussed above, it is important to make sure that the job applicant understands this relationship. 
• If the employer wants to condition any offer upon the results of a medical examination, it should include a statement to that effect, such as the following:

“If a job offer is made, employment may be contingent upon the successful completion of a medical examination, which may include providing body substance samples.”

• Kansas employers should remember that it is illegal to conduct a medical examination, or to request medical information, prior to a bona fide job offer.  Also, although a job offer can be conditioned upon a satisfactory medical examination, an employer covered by the ADA has a duty to provide “reasonable accommodations” to an applicant or employee.   
• A statement as to the length of time an application remains active, such as the following:

“This application for employment shall be considered active for a period of time not to exceed 45 days.  If you wish to be considered for employment beyond this time period, you should inquire as to whether or not applications are being accepted at that time.”

• A statement such as this limits the duration of an employer’s legal obligations and a job applicant’s rights that may be created by an employer accepting an application.
• A signed statement from the job applicant as to the truth of the information, such as the following:

“The information provided on the application is true, and I understand that false statements may be grounds for refusal to hire or for discipline, up to and including termination.”

• A statement, signed by the job applicant, acknowledging that he understands the employment-at-will relationship, such as the following:

“I understand that employment with the company is at-will, which means that employment can be terminated by the company or employee at any time, with or without cause, and with or without notice.”

• A statement signed by the job applicant, granting permission to the employer to investigate the information contained in the job application.  A statement such as this helps shield the employer, as well as third parties whom the employer might contact, from claims by the job applicant, including those for invasion of privacy.

Four sample employment applications have been provided below.  Before using any of these forms or inserting any additional information into any of these forms, employers are strongly encouraged to consult an employment attorney.

Sample 1


                                                                       (PLEASE PRINT ALL INFORMATION EXCEPT SIGNATURE)

THIS APPLICATION IS NOT AN EMPLOYMENT CONTRACT but
merely is intended to evaluate suitability for employment.
It is the policy of the company to provide equal employment
to all qualified persons without discrimination on the basis
of race, color, religion, national origin or ancestry, sex,
age (40+), disability, veteran status, or any other legally 
protected status under local, state, or federal law.  It is 
also the policy of the company to have the option of 
conducting pre-employment screening before a job offer is 
made. If a job offer is made, employment may be contingent 
upon the successful completion of a medical examination, 
which may include the applicant supplying body substance 
samples.  This application will remain active for 180 days.

                                                                       

                                              PERSONAL INFORMATION
Name Last First Middle 
Social Security #
Home Phone 
Work Phone
Please list below your current address and your 2 other most recent addresses:  Current Street City State Zip Since (Mo/Yr) 

Street City State Zip Since (Mo/Yr) 
Street City State Zip Since (Mo/Yr) 
 
EDUCATION
High School Attended 
City, County and State
Did you earn a Diploma?
Undergraduate College Attended 
City, State
Areas of Study
Degree/Certificate/Diploma
Graduate School Attended 
City, State
Areas of Study
Degree/Certificate/Diploma
Trade, Business or Other School 
City, State
Areas of Study
Degree/Certificate/Diploma

EMPLOYMENT INFORMATION
Position Applied For:
Date You Can  Start Work:
Desired Salary: $
Do You Prefer: oFull-Time oPart-Time
Can You Work: oWeekends oEvenings


Please answer all of the following questions. When necessary, note question number and use an extra paper to provide explanations:

1) Are you legally Authorized to work in the United States?         oYES oNO
2) Will you now or in the future require sponsorship for employment visa status (i.e. H-1B visa status)? oYES oNO
3) Will you work overtime when necessary? oYES oNO
4) Have you received a description of the job or been made aware of the essential functions of the job you are applying for : oYES oNO
5) Do you understand the job requirements? oYES oNO (If no, please explain)
6) Are you on layoff and subject to recall? oYES oNO
7) Are you currently bound by a noncompetition or trade secret agreement? (If yes, please explain) oYES oNO
8) Have you ever been discharged or asked to resign from a job? (If yes, please explain) oYES oNO 
9) Have you ever been convicted of or pled guilty to a felony or other crime? (If yes, please explain) oYES oNO  Conviction will not necessarily disqualify you from employment.

EMPLOYMENT HISTORY
MAY WE CONTACT YOUR PRESENT EMPLOYER? oYES oNO
Please list below your last 3 employers beginning with the most recent:

Most Recent Employer 
City
State
Zip Code
Phone 
Position Held Dates From/To
Pay Rate Upon Leaving  $
Supervisor
Duties Reason for Leaving 

Next Most Recent Employer
City
State
Zip Code
Phone 
Position Held Dates From/To
Pay Rate Upon Leaving  $
Supervisor
Duties Reason for Leaving 

Next Most Recent Employer
City
State
Zip Code
Phone 
Position Held Dates From/To
Pay Rate Upon Leaving  $
Supervisor
Duties Reason for Leaving 

Next Most Recent Employer
City
State
Zip Code
Phone 
Position Held Dates From/To
Pay Rate Upon Leaving  $
Supervisor
Duties Reason for Leaving 

JOB-RELATED SKILLS
Please answer the following questions if the position you are applying for requires driving a motor vehicle:
1. Do you have a valid driver’s license? oYES oNO  (If YES: Driver’s License Number) _______________________________________ 
Date of Issue:___________________________   
2. Have you been convicted of or pled guilty to any traffic-related offense within the past five years? oYES oNO  (Conviction will not necessarily disqualify you from employment.)   
3. Have you had your driver’s license suspended or revoked or had your driving privileges modified by a court of law? oYES oNO  (Suspension or revocation will not necessarily disqualify you from employment.)   
4. Please list all states from which you hold or have held a driver’s license: 
Please use this space to list any special skills you may have that relate to the position applied for:   
Please list any professional licenses, designations, certifications, etc. that may relate to the position applied for. Include date granted, name of organization and any other relevant information.  
1.   
2.   
3.
       
APPLICANT’S CERTIFICATION AGREEMENT
1. I authorize the investigation of all statements contained in this application and release from all liability any persons or employers supplying such information, and I also release the company from all liability that might result from making the investigation.  
2. I certify that the facts and information set forth in this application are true and complete to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of facts on this application (or on any required documents) will be cause for denial of employment or immediate discipline, up to and including termination of employment, regardless of when or how discovered.  
3. I agree, if I am offered and accept a position, to conform to all existing and future Company rules and regulations and I understand that the Company reserves the right to change policies, title, job description, wages, hours and working conditions as deemed necessary. I ALSO UNDERSTAND THAT, IF HIRED, MY EMPLOYMENT WILL BE AT-WILL, MEANING THAT EITHER PARTY CAN END THE EMPLOYMENT RELATIONSHIP AT ANY TIME AND FOR ANY OR NO REASON, AND THAT ONLY A WRITTEN AGREEMENT BETWEEN THE PRESIDENT OF THE COMPANY AND ME, SIGNED BY BOTH OF US, CAN ALTER THE AT-WILL EMPLOYMENT RELATIONSHIP.  
4. I understand that any employment offer is contingent upon my providing, within three (3) working days of employment, valid proof of identity and authorization to work in order to comply with the Immigration Reform and Control Act of 1986.  
5. I have read and reviewed the information supplied in this application and the above statements. By signing this application for employment I certify that I understand all parts of it and have answered all questions completely and fully.    
_______________________________  
Signature Date

Sample 2

We consider applicants for all positions without regard to
 race, color, religion, creed, gender, national origin, age,
 marital or veteran status, disability, or any other legally
 protected status.

(Please Print)

Position Applied for:
Date of Application:
How Did You Learn About Us? 

□ Advertisement □ Friend □ Walk-In  □ Employment Agency □ Relative □ Other______________________________

Last Name First Name Middle Name 
 

Address City State Zip Code 
Telephone Number(s)
Social Security Number


If you are under 18 years of age, can you provide required proof of your eligibility to work?  oYes oNo    

Have you ever filed an application with us before? oYes oNo                                        If Yes, give date  

Have you ever been employed with us before? oYes oNo If Yes, give date  

Are you currently employed? oYes oNo 

May we contact your present employer? oYes oNo 

Are you legally authorized to work in the United States? oYes oNo 

Will you now or in the future require sponsorship for employment visa status (i.e. H-1B visa status)? Yes No 

On what date would you be available to work?  

Are you available to work: o Full Time o Part Time o Shift Work o Temporary 

Are you currently on “layoff” status and subject to recall?                           oYes oNo 

Can you travel if a job requires it? oYes oNo 

Have you been convicted of a crime within the last 7 years?      oYes oNo  Conviction will not necessarily disqualify an applicant from employment. 

If Yes, please explain       

This application will remain active for 180 days.   


EDUCATION

Name and Address of School  Course of Study   Years  Completed  Diploma  Degree


Elementary  School




High  School




Undergraduate  College




Graduate  Professional




Other  (Specify)





Indicate any foreign languages you speak, read, and/or write

            Fluent    Well    Fair

Speak



Read



Write





Describe any specialized training, apprenticeship, skills and extra-curricular activities.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________








EMPLOYMENT EXPERIENCE  

Start with your present or last job. Include volunteer activities. You may exclude organizations that indicate race, color, religion, national origin or ancestry, sex, age (40+), disability, veteran status, or any other legally protected status under local, state, or federal law. 

1.
Employer

Dates Employed  From To
Work Performed






Address





Job Title

Hourly Rate/Salary  Starting Final








Telephone Number(s)





Reason for Leaving









2.
Employer

Dates Employed  From To
Work Performed






Address





Job Title

Hourly Rate/Salary  Starting Final








Telephone Number(s)





Reason for Leaving









3.
Employer

Dates Employed  From To
Work Performed






Address





Job Title

Hourly Rate/Salary  Starting Final








Telephone Number(s)





Reason for Leaving









  If you need additional space, please continue on a separate sheet of paper.    

ADDITIONAL INFORMATION

List professional, trade, business, or civic activities and offices held  You may exclude memberships that would reveal race, color, religion, national origin or ancestry, sex, age (40+), disability, veteran status, or any other legally protected status under local, state, or federal law:  __________________________________________________________________________________________________________________________________________________________________________________________________________________

Other qualifications  Summarize special job-related skills and qualifications acquired from employment or other experience.  ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 
 
Specialized Skills: Check Skills/Equipment Operated
Production/Mobile  oCRT oFax Machinery (list): 

Other (list):  oPC oLotus 1-2-3 ___________  oCalculator oPBX System _____________ ___________  oTypewriter oWordPerfect _____________ ___________

State any additional information you feel may be helpful to us in considering your application.
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 


References
_________________________________________( )________________  

Name Phone #  ________________________________________________________________________________________  

Address  _________________________________________( )________________  

Name Phone #  ________________________________________________________________________________________  

Address  ________________________________________________________________________________________  

_________________________________________( )________________  

Name Phone #  ________________________________________________________________________________________  

Address  ________________________________________________________________________________________ 

*WE ARE AN AT-WILL, EQUAL OPPORTUNITY EMPLOYER* 





 
FOR PERSONNEL DEPARTMENT USE ONLY


Position(s) Applied For Is Open: oYes oNo   

Position(s) Considered For: Date    NOTES:     


Applicant’s Statement
I certify that answers given herein are true and complete to the best of my knowledge.    

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.    

I understand that this application for employment shall be considered active for a period of time not to exceed 180 days and that if I wish to be considered for employment beyond this time period, I should inquire as to whether or not applications are being accepted at that time.   

I hereby understand and acknowledgethat, if hired, my employment relationship withthis organization would be of an “AT-WILL” nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time and for any or no reason. It is further understood that this “AT-WILL” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in WRITING BY an authorized executive of this organization.   In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge or a refusal to hire. I understand, also, that I am required to abide by all rules and policies of the employer.     

____________________________________ _________________________  

Signature of Applicant                   Date
   

*WE ARE AN AT-WILL, EQUAL OPPORTUNITY EMPLOYER*  


FOR PERSONNEL DEPARTMENT USE ONLY
Arrange Interview oYes oNo   ____________________________  

INTERVIEWER DATE   

Employed oYes oNo 

Date of Employment_________________________   

Hourly Rate/  Job Title Salary___________ 

Department__________________________  

By   NAME AND TITLE DATE

Sample 3


FOR OFFICE USE ONLY

Work  Location _______  
Position _______
Rate _______  
Date _______
(An Equal Opportunity Employer)

We consider applicants for all positions without regard torace, color, religion, national origin or ancestry, sex, age (40+), disability, veteran status, or any other legally protected status under local, state, or federal law. We will give this application every consideration. However, in accepting it, the Company makes no commitment of employment to the applicant. This application will remain active for 180 days.   

WE ARE AN AT-WILL EMPLOYER, MEANING THAT EITHER THE EMPLOYER OR THE EMPLOYEE MAY END THE EMPLOYMENT RELATIONSHIP AT ANY TIME AND FOR ANY OR NO REASON.

BASIC INFORMATION: Please print in ink
Position Applied For: 
Date of Application:
How Did You Learn About Us?  o Advertisement o Friend o Walk-In  o Employment Agency o Relative o Other______________________
Last Name First Name Middle Name  
Address City State ZIP Code  
Telephone Number(s)
Social Security Number

Salary requirements: 
Date Available:    
Have you been convicted of a crime within the last 7 years?   oYes o No  (Conviction will not necessarily preclude employment.)  If yes, please explain:   

Are you legally authorized to work in the United States? oYes    oNo  

Will you now or in the future require sponsorship for employment visa status (i.e. H-1B visa status)?   o Yes oNo   

*WE ARE AN AT-WILL, EQUAL OPPORTUNITY EMPLOYER*    

EMPLOYMENT HISTORY: Start with your present or most recent job. Include self-employment, summer and part-time jobs.

1
Company
Address
Telephone
Dates From To  Employed
Starting Leaving  Salary
Supervisor
Your Duties: 
Reason for Leaving: 

2
Company
Address
Telephone
Dates From To  Employed
Starting Leaving  Salary
Supervisor
Your Duties: 
Reason for Leaving: 

3
Company
Address
Telephone
Dates From To  Employed
Starting Leaving  Salary
Supervisor
Your Duties: 
Reason for Leaving: 

4
Company
Address
Telephone
Date From To  Employed
Starting Leaving  Salary
Supervisor
Your Duties: 
Reason for Leaving: 

If presently employed, why do you desire to change your position?_____________________________________________________________________________________________________   
If you are now employed, may we contact your present employer? oYes o No    

*WE ARE AN AT-WILL, EQUAL OPPORTUNITY EMPLOYER*     

REFERENCES:(not former employers or relatives)
Name 
Address
Phone Number


EDUCATION:
School
Name and  Address  of School
Course of  Study
Circle Last  Year  Completed
Did You  Graduate?
List  Diploma  or Degree
High
1 2 3 4
oYes  o No
College 
1 2 3 4
oYes  o No
Other  (Specify)
1 2 3 4
o Yes  o No
If you did not graduate, why did you leave school or college?___________________________________________________________________________________________________________   

Are you planning to pursue further studies? oYes oNo   
If yes, oDay OR oNight School  If so, when, where, and what courses?_______________________________________________  ____________________________________________________________________________________________________________________________________________________________   

INTERESTS:Use this space below to describe interest in the                                industry and skills and aptitudes that you feel qualify you for a position with our Company. (You may wish to include civic and community activities, professional societies in which you participate, hobbies, sports, special training or skills such as typing, accounting, and the like.) If you need more space, please continue on a separate sheet.  _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________    

*WE ARE AN AT-WILL, EQUAL OPPORTUNITY EMPLOYER*     

ACKNOWLEDGEMENT  Please Read Before Signing:  The facts set forth in my application for employment are true and complete. I understand that if employed, false or misleading statements on this application shall be considered immediate cause for dismissal.   I understand that, if the Company employs me, EITHER THE Company or I can terminate my employment with or without cause at any time and for any or no reason. I also understand that no official of the Company other than the Chief Executive Officer has any authority to enter into an agreement for employment for any specific period of time or to make any agreement contrary to the foregoing.     


  Signature of Applicant Date        
 
*WE ARE AN AT-WILL, EQUAL OPPORTUNITY EMPLOYER*

Sample 4

The Company is an equal opportunity employer and will not 
discriminate against any applicant on the basis of any 
characteristic that is protected by state or federal law.


THE COMPANY IS AN AT-WILL EMPLOYER, MEANING THAT EITHER 
THE EMPLOYER OR EMPLOYEE CAN END THE EMPLOYMENT 
RELATIONSHIP AT ANY TIME AND FOR ANY OR NO REASON.


Position Applied For:_______________________________ 
Date of Application:____________

Date You Can Start:_______________________________ 
           Please note that this application will                only           remain active for six months, after which     the applicant will need to reapply.


Name:__________________________________________         Social Security #:_____________

            Last                             First                            Middle


Present Address:________________________________________________________________

                                    Street                                                   City                 State              ZIP


Permanent Address:_____________________________________________________________

                                    Street                                                   City                 State             ZIP


Telephone #: Home (_____)___________________    Work  (_____)______________________


Are you 18 years or older?     oYes    oNo


Are there any hours or days of the week you cannot work?     oYes    oNo

              If so, when?____________________________________________________________   Salary Desired____________________ 


Type of Employment:      oFull-time    oPart-time


Are your employed now?      oYes    oNo 

            May we contact your present employer?    oYes    oNo


Did you ever apply to this Company before?     oYes    oNo    Where?___________________


            Under what name? _____________________________  
When?_____________________



EDUCATION:

NAME AND ADDRESS OF SCHOOL

NO. OF

YEARS

ATTENDED

DID YOU

  GRADUATE?

SUBJECT/

MAJOR

Elementary

School

High School

College

Specialized

Training

Are you legally authorized to work in the United States?    o Yes    o No

Will you now or in the future require sponsorship for employment visa status (i.e.  H-1B visa status)?    o Yes      o No


Have you ever been convicted of a crime except a minor traffic violation?      oYes    oNo

       {This question pertains only to convictions that have not been sealed or expunged.}

      (Conviction will not necessarily preclude employment.)

If so, please state citation, date and place where offense occurred:_____________________________________________________________________________________________________________________________________________________________________________________


Please provide any additional information such as special 
skills, training, management experience, equipment 
operation, or qualifications you feel will be helpful to us 
in considering your application:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


REFERENCES:  list three individuals not related to you, whom you have known for at least one year.

NAME

ADDRESS & TELEPHONE

RELATIONSHIP

YEARS

ACQUAINTED

Emergency Contact______________________________________________________________

                                    Name/Street/City/State/Telephone

CURRENT AND FORMER EMPLOYERS:(most recent one first)

DATE

MONTH/

YEAR

NAME, ADDRESS & TELEPHONE NO. OF EMPLOYER

SALARY:

STARTING/ENDING

LAST POSITION HELD/

RESPONSIBILITIES

REASON FOR LEAVING

From:




To:

From:




To:

From:




To:

From:




To:

From:




To:

(cont’d)


*  *  *


Please read the following statement carefully before signing to indicate your understanding:


I understand that if I receive a conditional job offer, and prior to beginning employment, I may be requested to undergo a pre-employment medical examination and/or drug and alcohol testing. In the event that I have a disability that will affect my ability to take the test, I will so inform the Company prior to the administration of the test so that a reasonable accommodation can be made. The Company reserves the right to require medical documentation regarding the need for accommodation.


I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application may result in a refusal to hire or, if I am hired, discipline up to and including termination.


I understand and agree that, if hired, my employment is AT-WILL. THIS MEANS THAT, IF I AM HIRED, EITHER THE COMPANY OR I CAN END THE EMPLOYMENT RELATIONSHIP AT ANY TIME, WITH OR WITHOUT NOTICE, AND FOR ANY OR NO REASON.


I authorize investigation of all statements contained in this application for any employment-related purpose. I release the listed references and all employers to provide you with any and all applicable information they may have. I hereby release these references and former employers from all liability for any information they may give to you, including but not limited to any defamation claims I may now have or will have against them.




________________    ______________________________________________________

Date                            Signature





*THE COMPANY IS AN AT-WILL, EQUAL OPPORTUNITY EMPLOYER*

For Employer Use Only

Interviewed By:________________________ Date:_________________ Hired:     oYes    oNo


Starting Date:____________________ Position:_______________ Wage:______________

Employment Application – Supplemental Form


__________________Driving History__________________________

If the position you seek requires you to drive a vehicle, please answer the following questions:


Do you have a valid driver’s license?           Yes            No

If yes, list state, number, and expiration date: ___________________________________________________________________________________________________________


List all states from which you have held a driver’s license and dates held: ___________________________________________________________________________________


Has your driver’s license, permit, or privileges ever been suspended, revoked, or cancelled?           Yes      No

If so, list state(s), date(s), and reason(s): _______________________________________________________________________________________________________________


Have you ever been denied a driver’s license, permit, or privilege to drive by a government agency or employer:  Yes      No

If yes, list date(s), government agency(ies)/employer(s), and reason(s): ____________________________________________________________________________________________________________________________________________________________


Have you ever been charged with any traffic-related offenses?             Yes        No

If yes, list all offense(s), date(s), location(s), and result(s): ______________________________________________________________________________________________________________________________________________________________________


If the position you seek requires you to operate a commercial motor vehicle, please provide the names of all employers for whom you operated a commercial motor vehicle during the past 10 years: ____________________________________________________________ ________________________________________________________________________________________________________________________________________________


Note:  Be sure that these employers, addresses, dates of employment, and reasons for leaving are identified in the employment history section of the application.


During the previous two years, have you:

1)     Had an alcohol test result of 0.04 alcohol concentration or greater?          Yes      No

2)     Had a verified positive controlled substance test result?                           Yes      No

3)     Refused to take an alcohol or drug test?                                                     Yes      No