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PERSONAL INFORMATION:

Date*

Phone*

Driver's License / State Identification No.*

State Issued By*

Are you either a US Citizen or an alien authorized to work in the United States?*

Are you 18 years or older?*

(Completed I-9 Form will be verified upon hiring as required by the Immigration Reform and Control Act of 1986)

EMPLOYMENT DESIRED:

Position*

Date you can start*

Salary Desired*

Are you currently employed?*

If yes, may we inquire of your present employer?*

Have you ever applied to this company before?*

EDUCATION:

Grammar School

Name and Location

# of years attended *

Did you graduate?*

Subject studied

High School

Name and Location

# of years attended *

Did you graduate?*

Subject studied

College

Name and Location

# of years attended *

Did you graduate?*

Subject studied

Trade, Business or Correspondence School

Name and Location

# of years attended *

Did you graduate?*

Subject studied

* The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age.

GENERAL

Subjects of special study or research work

U.S. Military Branch of Service

Technical Specialization

Rank Attained

Present membership in National Guard or Reserves?*

LEGAL INFORMATION

Were you ever discharged by any company?*

If yes, give name of company(ies):

Reason for discharge

Have you ever been convicted of a crime other than a minor traffic violation?*

If yes, please explain offense and final disposition

EMPLOYMENT HISTORY

(List your last three employers, starting with the most recent)

Name of employer

Name & phone number of supervisor

From

To

Salary

Position Held

Reason for Leaving

Name of employer

Name & phone number of supervisor

From

To

Salary

Position Held

Reason for Leaving

Name of employer

Name & phone number of supervisor

From

To

Salary

Position Held

Reason for Leaving

REFERENCES

Give the names and phone numbers of three persons not related to you, whom you have known at least one year.

Name

Phone

Business

Years Acquainted

Name

Phone

Business

Years Acquainted

Name

Phone

Business

Years Acquainted

PHYSICAL RECORD

Do you have any physical limitations that preclude you from performing any work for which you are being considered?*

If yes, what can be done to accommodate your limitation?*

Please describe

We require all employees to be vaccinated. Are you vaccinated against COVID-19?*

Do you have a valid medical or religious exemption for not receiving a COVID-19 vaccine?*

VARIOUS FEDERAL, STATE AND LOCAL LAWS PROHIBIT DISCRIMINATION BASED ON RACE, COLOR, SEX, RELIGION, NATIONAL ORIGIN, ANCESTRY, AGE, DISABILITY OR MARITAL STATUS. POGODA MANAGEMENT CO. IS AN EQUAL OPPORTUNITY EMPLOYER AND YOUR RESPONSE TO ANY QUESTION WILL NOT BE USED AS A BASIS FOR DISCRIMINATION BUT WILL BE JUDGED ON ITS RELEVANCE TO THE POSITION YOU ARE SEEKING.

Upon the signing of this application, I represent that all of the information now or hereafter given by me in support of my application is true and complete. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in immediate dismissal. I understand, also, that I am required to abide by all rules and regulations of Pogoda Management Co. I authorize you to obtain a credit report using the social security number, which I have provided you, and I understand that you will, in compliance with the Fair Credit Reporting Act, provide me with a complete copy of that report upon my request. I authorize you to verify any of the information concerning my employment, education, credit, driving, criminal or medical history with the appropriate individuals, companies, institution or agencies, and I authorize them to release such information as you require, including my prior disciplinary employment record, without any obligation to give me written notice of such disclosure. I hereby release you and them from any liability whatsoever as a result of any such inquiries and disclosures. I agree that any false information in support of my application may subject me to discharge at any time during the period of my employment. I further agree that my employment is conditional until such time as the results of my pre-employment reference and records review is complete.

I agree that either party may terminate the employment relationship, with or without cause, at any time, and I further agree that this arrangement may only be altered in writing directed to me personally and signed by an officer of Pogoda Management Co. I agree that I shall be bound by the other rules, policies, regulations and terms and conditions of employment of the firm as they are from time to time changed, and no additional obligations can be imposed on the company except those, which have been acknowledged in writing, by the president of the company or his designated representative(s). I hereby authorize the firm to deduct from each and every period of my pay any amount necessary to offset any damages caused by me or the value of property or money entrusted to me by, or owed by me to the firm during the course of my employment. I agree that any action or suit against the firm arising out of my employment or termination of employment, including, but not limited to, claims arising under State or Federal civil rights statutes, must be brought within 180 days of the event giving rise to the claims or be forever barred. I waive any limitation periods to the contrary. I further agree that if I should bring any action or claim arising out of my employment against the firm in which the firm prevails, I will pay to the firm any and all such costs incurred by the firm in defense of said claims or actions, including attorney fees.

SIGNATURE (Type Full Name)

Date

Rev. 5/2021

Comments

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APPLICATION FOR EMPLOYMENT

PERSONAL INFORMATION:

EMPLOYMENT DESIRED:

EDUCATION:

GENERAL

LEGAL INFORMATION

EMPLOYMENT HISTORY

REFERENCES

PHYSICAL RECORD