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Employment Application
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Applicant Information
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First Name
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Last Name
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Address
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CIty
*
State
*
Zip
*
Phone
*
Alternate Phone
Email
Position(s) Applied For
*
Date of Application
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MM slash DD slash YYYY
Have you ever submitted an application here before?
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Yes
No
If so, when?
Have you ever been employed here before?
*
Yes
No
If so, when?
Are you 18 years or older?
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Yes
No
Are you willing to travel?
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Yes
No
References
Fields marked with an * are required
Name
*
Phone
*
Years Known
*
Name
Phone
Years Known
Education
Fields marked with an * are required
Name of High School
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Location
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Years Completed
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Course of Study
Did You Graduate
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Yes
No
Name of College
Location
Years Completed
Course of Study
Did You Graduate
Yes
No
Military Background
Branch
Rank at DIscharge
Past Employment
Fields marked with an * are required
Employer 1
Last Employer Name
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Address
*
Supervisor & Title
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Phone
*
Position Held
*
From
*
MM slash DD slash YYYY
To
*
MM slash DD slash YYYY
Reason for Leaving
*
Add Employers
Employer 2
Employer 3
Employer 4
Employer 2
Last Employer Name
Address
Supervisor & Title
Phone
Position Held
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Reason for Leaving
Employer 3
Last Employer Name
Address
Supervisor & Title
Phone
Position Held
To
MM slash DD slash YYYY
From
MM slash DD slash YYYY
Reason for Leaving
Employer 4
Last Employer Name
Address
Supervisor & Title
Phone
Position Held
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Reason for Leaving
Skills
Fields marked with an * are required
Skills & Qualifications
*
I certify that the information in this application is true and understand that misrepresentations or false or omitted facts may result in my termination, regardless of the time of discovery by the company. I also understand that, if hired, my employment is for no definite period and may be terminated at any time without written notice and that, absent a written contract signed by the President of the company, I will remain an at-will employee and can be terminated at any time without any notice. I authorize investigation of the statements contained herein and the references listed above to give you any and all information concerning my previous employment and any pertinent information such references may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you. I understand that if the company decides to engage an investigative consumer reporting agency to report on my credit and personal history, the company will provide me, at my request, with the name and address of the agency so that I can obtain from them the nature and substance of the information contained in the report.
Name
*
Date
*
MM slash DD slash YYYY
Self-Identify Invitation
Fields marked with an * are required
Name
*
We are obligated to report demographic information about our employees and job applications to the U.S. Department of Labor (DOL) and/or the Equal Employment Opportunity Commission (EEOC). The government suggests we invite individuals such as yourself to provide information to us directly. We agree that this approach produces more accurate information. As an employer of 100 or more people, and/or an affirmative action employer with federal contracts exceeding $50,000 and 50 or more workers, we are required to create and maintain this information on all employees. We are also required to request the information from job applicants. Job applicants are not required to respond. Yet, we ask you to do so because we wish our statistical analysis to be as accurate as possible. Missing or inaccurate information can produce results that aren't accurate.
Please place a check in the appropriate boxes below.
Gender
Male
Female
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Ethnicity (Only if Not Hispanic or Latino)
American Indian/Alaska Native
Asian
Black/African American
Native Hawaiian/Pacific Islander
White
Two or More Races
Hispanic or Latino -
A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
American Indian or Alaska Native (Not Hispanic or Latino) -
A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.
Asian (Not Hispanic or Latino) -
A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.
Black or African American (Not Hispanic or Latino) -
A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) -
A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
White (Not Hispanic or Latino) -
A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Two or More Races (Not Hispanic or Latino) -
Persons who identify with two or more race/ethnic categories named above.
(PLEASE NOTE: If you are given a job offer, you will be invited to identify at that time any disability for which you need an accommodation, or your status as a US. military veteran.)
Voluntary Self-Identification of Disability
Why are you being asked to complete this form?
We are a federal contractor or subcontractor. The law requires us to provide equal employment opportunity to qualified people with disabilities. We have a goal of having at least 7% of our workers as people with disabilities. The law says we must measure our progress towards this goal. To do this, we must ask applicants and employees if they have a disability or have ever had one. People can become disabled, so we need to ask this question at least every five years.
Completing this form is voluntary, and we hope that you will choose to do so. Your answer is confidential. No one who makes hiring decisions will see it. Your decision to complete the form and your answer will not harm you in any way. If you want to learn more about the law or this form, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.
Please Select One:
*
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 decline to self-identify
PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number.
How do you know if you have a disability?
A disability is a condition that substantially limits one or more of your “major life activities.” If you have or have ever had such a condition, you are a person with a disability. Disabilities include, but are not limited to:
Alcohol or other substance use disorder (not currently using drugs illegally)
Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, HIV/AIDS
Blind or low vision
Cancer (past or present)
Cardiovascular or heart disease
Celiac disease
Cerebral palsy
Deaf or serious difficulty hearing
Diabetes
Disfigurement, for example, disfigurement caused by burns, wounds, accidents, or congenital disorders
Epilepsy or other seizure disorder
Gastrointestinal disorders, for example, Crohn's Disease, irritable bowel syndrome
Intellectual or developmental disability
Mental health conditions, for example, depression, bipolar disorder, anxiety disorder, schizophrenia, PTSD
Missing limbs or partially missing limbs
Mobility impairment, benefiting from the use of a wheelchair, scooter, walker, leg brace(s) and/or other supports
Nervous system condition, for example, migraine headaches, Parkinson’s disease, multiple sclerosis (MS)
Neurodivergence, for example, attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder, dyslexia, dyspraxia, other learning disabilities
Partial or complete paralysis (any cause)
Pulmonary or respiratory conditions, for example, tuberculosis, asthma, emphysema
Short stature (dwarfism)
Traumatic brain injury
Veteran Status
Please Select One:
*
I identify as one or more of the classifications of protected veteran listed below
I am not a protected veteran
I decline to self-identify
Shafer Contracting Co Inc. 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. If you believe you belong to any of the categories of protected veterans listed below, 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.
A "disabled veteran" is one of the following:
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
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.
