Jobs Application

General Information

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Date

First Name(Required)

Middle Name(Required)

Last Name(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Home Phone(Required)

Business Phone

Are you under 18?(Required)

If yes, what is your date of birth?

Are you either: (1) a U.S. citizen or, if not (2) do you currently have lawful employment authorization that permits you to work for the Company without the Company having to take any action, either upon employment, or at any date in the future, to ensure or assist you in maintaining lawful employment authorization to work for the Company?(Required)

Answer the following question: Are you a student on a temporary visa? Proof of authorization to work will be required if you are employed by Patz Corporation.

Role & Availability

Position Desired(Required)

Pay Expected(Required)

When are you available to begin work?(Required)

Are you available for full-time work?(Required)

How many hours per week can you work?

Will you work overtime if asked?(Required)

Special training or skills? (languages, machine operation, etc.)

Are you currently on lay-off and subject to call back?(Required)

Have you filed an application here before?(Required)

if yes, when?

Have you ever worked here before?(Required)

if yes, when?

(1) Have you ever been convicted of, plead nolo contendere (no contest) to, or been fined in connection with any felony, misdemeanor, municipal ordinance violation, or any other type of offense (other than a parking ticket), regardless of the nature of the penalty or fine for that offense?(Required)

(If you are in doubt about the nature of any offense, please list; this question is designed to require disclosure of all past convictions, violations, fines or offenses, and the failure to list a conviction, offense, violation or fine will be considered falsification and will be grounds for refusal to hire or termination of employment. However, no application will be denied a position because of past conviction, offense, violation or fine, which is not substantially related to the circumstances of the employment sought.)

If yes, provide details

(2) Are you currently subject to a pending criminal charge for any misdemeanor or felony?(Required)

(If you are in doubt about the nature of any offense, please list; this question is designed to require disclosure of all past convictions, violations, fines or offenses, and the failure to list a conviction, offense, violation or fine will be considered falsification and will be grounds for refusal to hire or termination of employment. However, no application will be denied a position because of past conviction, offense, violation or fine, which is not substantially related to the circumstances of the employment sought.)

If yes, provide details

Post Secondary Education

College Name

Course of Study

Years Completed

Degree or diploma?

Did you graduate?

High School Education

High School Name(Required)

Course of Study(Required)

Years Completed(Required)

Degree or diploma?(Required)

Did you graduate?(Required)

Military Experience

Complete this section if you served in the U.S. Armed Forces

Describe your duties and any special training

Branch of service

Rank at discharge

Work History 1

Company Name(Required)

Company Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employment Start

Employment End

If still employed, leave blank

Supervisor Name

Starting Hourly Pay

Please note salary or hourly.

Most Recent Pay

Please note salary or hourly.

Reason for leaving

State your title and describe work

May we contact this employer to verify your employment?

Work History 2

Company Name

Company Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employment Start

Employment End

If still employed, leave blank

Supervisor Name

Starting Hourly Pay

Please note salary or hourly.

Most Recent Pay

Please note salary or hourly.

Reason for leaving

State your title and describe work

May we contact this employer to verify your employment?

Work History 3

Company Name

Company Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employment Start

Employment End

If still employed, leave blank

Supervisor Name

Starting Hourly Pay

Please note salary or hourly.

Most Recent Pay

Please note salary or hourly.

Reason for leaving

State your title and describe work

May we contact this employer to verify your employment?

Resume

Please upload your resume below

File

Max. file size: 512 MB.

Reference 1

Reference Name

Relationship

Home Phone

Work Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

What's the Best Time to Contact this Person (CST)?

between 6:30 a.m. - 4:30 p.m. CST

Is it okay to contact this person at work?

Reference 2

Reference Name

Relationship

Home Phone

Work Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

What's the Best Time to Contact this Person (CST)?

between 6:30 a.m. - 4:30 p.m. CST

Is it okay to contact this person at work?

Reference 3

Reference Name

Relationship

Home Phone

Work Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

What's the Best Time to Contact this Person (CST)?

between 6:30 a.m. - 4:30 p.m. CST

Is it okay to contact this person at work?

Voluntary Affirmative Action Information

In an effort to implement our voluntary government affirmative action program record keeping and reporting requirements, we ask that you complete this data survey. Your cooperation is appreciated. Providing this information is STRICTLY VOLUNTARY. Failure to provide it will not subject you to discharge or discipline or any other negative personnel action. Information provided will be kept confidential in accordance with applicable regulations.

Name

Position Applied For

Gender

Ethnic Group: (please check one):

Racial Groups: If Non-Hispanic or Latino was selected, please select one of these race categories:

Invitation to self-identify protected veteran status

I identify as one or more of the classifications of protected veteran listed below

I am not a protected veteran

I choose not to disclose this information.

This employer, Patz Corporation, is a Government contractor subject to the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. §4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications are defined below:

A “disabled veteran” is one of the following: (a) a veteran a veteran of the U.S. military, ground, naval, or air service 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 Secretary of Veterans Affairs; or (b) a person who was discharged or released from active duty because of a service-connected disability
A “recently separated veteran” means any veteran during the three-year period beginning on the date of such veteran’s discharge or release from active duty in the U.S. military, ground, naval, or air service.
An “active duty wartime or campaign badge veteran” means a veteran who served on active duty in the U.S. military, ground, naval, or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.
An “Armed forces service medal veteran” means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

Protected veterans may have additional rights under USERRA - the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor’s Veterans Employment and Training Service (VETS), toll-free, at 1-866-4-USA-DOL.

If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below. As a Government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.

Voluntary Self-Identification of Disability

Please review the information from provided on this pdf form and answer the following question:

Name

Date

Please select one of the following

Yes, I have a disability, or have had one in the past

No, I do not have a disability and have not had one in the past

I do not want to answer

Submission

Electronic Signature(Required)

Phone

This field is for validation purposes and should be left unchanged.

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Patz Employment Application

General Information

Role & Availability

Post Secondary Education

High School Education

Military Experience

Work History 1

Work History 2

Work History 3

Resume

Reference 1

Reference 2

Reference 3

Voluntary Affirmative Action Information

Voluntary Self-Identification of Disability

Submission

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