Describe any specialized training,
apprenticeship, skills and extra-curricular activities.
Describe any job-related training received in
the United States military.
Production/Mobile Machinery
(list)
Other: (State any additional in formation you feel may be helpful
to us in considering your application.)
Note to Applicants: DO NOT ANSWER THIS
QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR
WHICH YOU ARE APPLYING.
Are you capable of performing in a
reasonable manner, with or without a reasonable accommodation, the
activities involved in the job or occupation for which you have applied? A
review of the activities involved in such a job or occupation has been
given.
NO
Personal/Professional References
Do not include family members or past supervisors.
APPLICANT’S STATEMENT
I certify that answers given herein are
true and complete.
I authorize investigation of all statements
contained in this application for employment as may be necessary in
arriving at an employment decision. This application for employment shall
be considered active for a period of time not to exceed 45 days. Any
applicant wishing to be considered for employment beyond this time period
should inquire as to whether or not applications are being accepted at
that time.
I hereby understand and acknowledge that,
unless otherwise defined by applicable law, any employment relationship
with this organization is of an "at will" nature, which
means that the Employee may resign at any time and the Employer may
discharge Employee at any time with or without cause, 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. I understand, also, that I am
required to abide by all rules and regulations of the employer.
Name of Applicant
(Please
note: this portion is being included for informational purposes only, the
legal document will be completed at the time of hiring.)
EMPLOYMENT ELIGIBILITY VERIFICATION (Form I-9)
EMPLOYEE INFORMATION AND VERIFICATION: (To be completed and
signed by employee.)
Date of Birth (Month/Day/Year)
Social
Security Number
I attest, under penalty of perjury, that I am
(check a box):
(Alien Number A
or
Admission Number , expiration of employment authorization, if any
I attest , under
penalty of perjury, the documents that I have presented as evidence of
identity and employment eligibility are genuine and relate to me. lam
aware that federal law provides for imprisonment and/or fine for any false
statements or use of false documents in
connection with this certificate.
Name:
Signature Date (Month/Day/Year)
PREPARER/TRANSLATOR CERTIFICATION: (To be
completed if prepared by person other than the employee). I attest, under
penalty of perjury, that the above was prepared by me at
the request of the named individual and is based on all information of which I
have any knowledge.
Signature Name (Print or Type)
Address (Street Name and Number)
City
State Zip
Code
EMPLOYER REVIEW AND VERIFICATION:
To be completed and signed by employer.
( Please
note: this portion is being included for informational purposes only, the
legal document will be completed at the time of hiring.)
Instructions: Examine
one document from List A and check the appropriate box OR and
Provide the Document Identification
Number and Expiration Date for the document checked.
List A List B List C
Documents that Establish Identity and
Employment Eligibility Documents that Establish Identity Documents that Establish Employment
Eligibility
1. United States Passport 1. A State-issued driver’s license or a
State-issued I.D. card with a photograph, or information, including
name, sex, date of birth, height, weight, and color of eyes. (Specify
State) 1. Original Social Security Number Card
(other than a card stating it is not valid for employment)
2. Certificate of United States Citizenship 2. U.S. Military Card 2. A birth certificate issued by State,
county, or municipal authority bearing a seal or other certification
3. Certificate of Naturalization 3. Other (Specify document and issuing
authority) 3. Unexpired INS Employment Authorization
Specify form
4. Unexpired foreign passport with attached
Employment Authorization
5. Alien Registration Card with photograph
Document Identification Document Identification Document Identification
Expiration Date (if
any) Expiration Date (if
any) Expiration Date (if
any)
CERTIFICATION: I
attest, under penalty of perjury, that I have examined the documents presented
by the above individual, that they appear to be genuine and to relate to the
Individual named, and that the individual, to the best of any knowledge, Is
eligible to work in the United States.
Signature Name:___________________________ Title:___________________________
Employer Name:___________________________ Address:___________________________ Date:_______________
Form 1-9 (05/07/87) 0MB No. 1115-0136
U.S. Department of Justice Immigration and
Naturalization Service
Employment Eligibility Verification
NOTICE: Authority
for collecting the information on this form is in Title 8, United States
Code, Section 1324A, which requires employers to verify employment
eligibility of individuals on a form approved by the Attorney General.
This form will be used to verify the individual’s eligibility for
employment in the United States. Failure to present this form for
inspection to officers of the Immigration and Naturalization Service or
Department of Labor within the time period specified by regulation, or
improper completion or retention of this form, may be a violation of the
above law and may result in a civil money penalty.
Section 1. Instructions to
Employee/Preparer for completing this form
Instructions for the employee.
(For the purpose of completion of this form the term
"hired" applies to those employed, recruited or referred for a fee.)
All employees must print or type their complete name,
address, date of birth, and Social Security Number. The block which
correctly indicates the employee’s immigration status must be checked.
If the second block is checked, the employee’s Alien Registration
Number must be provided. If the third block is checked, the employee’s
Alien Registration Number
or Admission
Number must be provided, as well as the date of expiration of that
status, if it expires.
All employees whose present names differ from birth
names, because of marriage or other reasons, must print or type their
birth names in the appropriate space of Section 1. Also, employees whose
names change after employment verification should report these changes
to their employer.
All employees must sign and date the form.
Instructions for the preparer of the form,
if
not the employee.
If a person assists the employee with completing this
form, the preparer must certify the form by signing it and printing or
typing his or her complete name and address.
NOTE: Employers
are
responsible for reverifying employment eligibility of employees
whose employment eligibility documents carry an expiration date. Copies of documentation presented by an individual
for the purpose of establishing identity and employment eligibility
may be copied and retained for the purpose of complying with the
requirements of this form and no other purpose. Any copies of
documentation made for this purpose should be maintained with this
form.
Name changes of employees which occur after
preparation of this form should be recorded on the form by lining
through the old name, printing the new name and the reason (such as
marriage), and dating and initialing the changes. Employers should not
attempt to delete or erase the old name in any fashion.
RETENTION OF RECORDS.
The completed form must be retained by the
employer for:
• three years after the date of
hiring; or
• one year after the date the
employment is terminated, whichever is later.
U. S. Department
of Justice 0MB #1115-0136
Immigration and Naturalization Service
Form
1-9 (05/07/
87
Employers may photocopy or reprint this form as
necessary.
