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Application for Employment

EEO Statement:

Republic Wire respects diversity and accordingly is an equal opportunity employer. Employment decisions are made without regard to race, color, religion, creed, national origin, citizenship status, ancestry, age, physical or mental disability, gender, sex, marital status, pregnancy (or related condition), sexual orientation, gender identity, veteran status, genetic information or any other factors that are protected by applicable federal, state or local law. We are firmly committed to a policy of equal opportunity in all areas of employment including recruiting, selection, training, assignment, access to facilities and programs, promotion, termination, compensation and benefits.

Application Instructions

Please complete each section in its entirety. Provide full and accurate answers. A resume may be requested and submitted but will not replace the employment application.

Contact Information:

Name*

Email*

Phone*

Address*

Employment Questions:

Position(s) Applying For:*

Salary Expectations (Hourly or Salary):*

Name:

Relationship:

For driving job only: Do you have a valid driver's license?

Yes

No

Driver's License Number:

State:

Education

Please include name, address, city, and state for each school. Include number of years completed, degree, and major course of study for each school.

High School:*

College:*

Trade, Business, Night School:*

Special Skills: List any job-related skills or qualifications that support your application and the job for which you are applying:*

Employment Experience

List all former jobs (most recent job first). Account for all time periods including unemployment, self-employment, and military service.

Employer:*

Dates Employed (From/To):*

Address*

Job Title:*

Starting hourly rate or salary:*

Phone*

-

Immediate Supervisor:*

Ending:*

Work Performed:*

Reason for Leaving:*

Employer:

Dates Employed (From/To):

Address

Job Title:

Starting hourly rate or salary:

Phone

-

Immediate Supervisor:

Ending:

Work Performed:

Reason for Leaving:

Employer:

Dates Employed (From/To):

Address

Job Title:

Starting hourly rate or salary:

Phone

-

Immediate Supervisor:

Ending:

Work Performed:

Reason for Leaving:

May we contact your present employer?*

Yes

No

May we contact your previous employers?*

Yes

No

Please identify any exceptions and reasons for not contacting present or prior employers:

Have you ever been dismissed or forced to resign from employment?*

Yes

No

If yes, please explain:

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Professional References:

List three persons, not relatives, whom you have known at least one year.

Name:*

Telephone Number:*

-

Telephone Number:*

-

Telephone Number:*

-

Occupation:*

Notice to Applicants:

This company complies with the Americans with Disabilities Act of 1990, as amended. During the interview process, you may be asked questions concerning your ability to perform job-related functions. If you are given a conditional offer of employment, you may be required to complete a post-job offer medical history questionnaire and undergo a medical examination. All entering confidential and in separate files. An applicant that needs a reasonable accommodation during the application and/or interview process should notify Human Resources.

Applicant's Statement:

I certify that the answers given herein are true and complete to the best of my knowledge. I authorize the investigation of all matters contained in this application and hereby give permission to contact schools, previous employers, references, and others in order to verify the facts and information furnished with regard to my character and qualifications, and hereby release employers, schools, and other persons from all liability in responding to inquiries in connection with this application. I understand that misrepresentations, omissions of facts or incomplete information requested in this application may remove me from further consideration fro employment. In addition, if employed, any misrepresentations or omissions of facts called for in this application will be cause for dismissal at any time without any previous notice.

Applicants accepted for employment should clearly understand that while we make every effort to provide steady, continuous work, we have no employment contracts, and we cannot guarantee the permanencies of any position. Job tenure can be affected by many factors including business/economic conditions, changes in laws or employee policies, conformity to our work rules, job performance, etc. and, or course, employees may elect to leave on their own accord to seek other jobs.

I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete background check and drug screening. I hereby consent to a pre- and/or post-employment drug screen as condition of employment, if required.

If I am offered and accept employment with the aforementioned company, I understand that my employment is for no specific term and may be terminated by myself or the employer with or without notice or cause at any time. I further understand that an oral promise, policy, custom, business practice or other procedure (including any employee handbook or any personnel manuals) does not constitute an employment contract or modification of the at-will employment relationship between myself and this employer.

Signature:*

Date:*

*By typing your name and selecting the date you agree that this will be an electronic representation of your signature, just the same as a pen-and-paper signature.

Applicant Authorization and General Release

I hereby authorize Republic Wire Inc and TRAK-1 (herein known as "Agent") to request and receive any and all background information about or concerning me, including but not limited to my Criminal History, Credit History including a consumer report under the Fair Credit Reporting Act, 15 U.S.C. 1681 et seq. (the "Act"), Driving Record, Employment History, Landlord/Tenant History, Civil Listings, Educational Background, Professional License from any Individual, Corporation, Partnership, Law Enforcement Agency, Institution, School, Organization, Credit Bureau, State Boards, Licensing Agency, and other entities including my Present and Past Employers.

I further release and discharge Republic Wire Inc. and it's "Agent" (Trak-1.) and all of their Subsidiaries, Affiliates, Officers, Employees, Contract Personnel, or Associates, from any and all claims and liability arising out of any request(s) for, or receipt of, information or records pursuant to this authorization, procurement of an investigative consumer report and understand that it may contain information about my character, general reputation, personal characteristics, and mode of living, whichever are applicable.

I understand that I have the right to make written request within a reasonable period of time to the original provider of consumer information for additional information concerning the nature and scope of investigation. I acknowledge that I have voluntarily provided the above information for employment application purposes, and I have carefully read and I understand this authorization.

Signature:*

Date:*

*By typing your name and selecting the date you agree that this will be an electronic representation of your signature, just the same as a pen-and-paper signature.

Previous (former) Names:

Social Security #:*

Driver's License #:*

Date of Birth:*

State Issued:*

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