Application For Employment


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NameApplication For Employment
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3825 85th Avenue North

Brooklyn Park, MN 55443

Tel. (763) 425-8822 * Fax. (763) 425-5636

Application For Employment

3825 85th Avenue North

Brooklyn Park, MN 55443

Tel. (763) 425-8822 * Fax. (763) 425-5636










PLEASE COMPLETE PAGES 1-4.

DATE TK!001!

Name TK!002! TK!003! TK!004! TK!005!

Last First Middle Maiden

Present address TK!006! TK!007! TK!008! TK!009!

Number Street City State Zip

How long TK!010!




Telephone TK!011!

Are you 18 years of age or older? _TK!012! Yes _TK!013! No

Are you lawfully employable in the US either by virtue of citizenship or
by having authorization from the INS or the Labor Dept?
_TK!208! Yes _TK!209! No

Position applied for:
TK!014!

Salary desired: TK!015!

(Be specific)

Days/hours available to work:

No Pref TK!016! Thur TK!020!____

Mon TK!017! Fri _ TK!021!____

Tue TK!018! Sat TK!022!____
Wed TK!019! Sun TK!023!____



How many hours can you work weekly? TK!024! Can you work nights? TK!025!

Employment desired _TK!026! FULL-TIME ONLY _TK!027! PART-TIME ONLY _TK!028! FULL- OR PART-TIME

When available for work? TK!029!

Are you willing to travel? _TK!210! Not willing to travel _TK!211! 0-25% _TK!212! 25-50% _TK!213! 50-75% _TK!214! 75-100%

Are you willing to relocate? _TK!215! Yes _TK!216! No



TYPE OF SCHOOL

NAME OF SCHOOL

LOCATION
(Complete mailing address)


NUMBER OF YEARS COMPLETED

MAJOR & DEGREE

High School

TK!031!

TK!032!

TK!033!



















College

TK!034!

TK!035!

TK!036!

TK!037! / TK!038!
















Bus. or Trade School

TK!039!

TK!040!

TK!041!

TK!042! / TK!043!
















Professional School

TK!044!

TK!045!

TK!046!

TK!047! / TK!048!



















HAVE YOU EVER BEEN CONVICTED OF A CRIME? _TK!049! No _TK!050! Yes

If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.

TK!051!



3825 85th Avenue North

Brooklyn Park, MN 55443

Tel. (763) 425-8822 * Fax. (763) 425-5636




3825 85th Avenue North

Brooklyn Park, MN 55443

Tel. (763) 425-8822 * Fax. (763) 425-5636

APPLICATION FOR EMPLOYMENT

CAN YOU PERFORM THE ESSENTIAL FUNCTIONS OF THE JOB WITH OR WITHOUT A REASONABLE ACCOMMODATION? _TK!217! Yes _TK!218! No

DO YOU HAVE A DRIVER’S LICENSE? _TK!052! Yes _TK!053! No

Driver’s license
number
_TK!054! State of issue _TK!055! _TK!056!Operator _TK!057!Commercial (CDL) _TK!058!Chauffeur

Expiration date _TK!059!

List Equipment Experience_TK!060!

Have you had any accidents during the past three years? _TK!061!

How many? _TK!062!

Have you had any moving violations during the past three years? _TK!063!

How Many? _TK!064!




OFFICE ONLY







_TK!065! Yes _TK!068! Yes Word _TK!070! Yes

Typing _TK!066! No _TK!067! WPM 10-key _TK!069! No Processing _TK!071! No _TK!072! WPM

Personal _TK!073! Yes PC _TK!075!

Computer _TK!074! No Mac _TK!076!

Other Skills _TK!077!




Please list two references other than relatives or previous employers.

Name TK!078!

Name TK!084!

Position TK!079!

Position TK!085!

Company TK!080!

Company TK!086!

Address TK!081!

Address TK!087!

TK!082!

TK!088!

Telephone TK!083!

Telephone TK!089!




An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying.

TK!090!




MILITARY







HAVE YOU EVER BEEN IN THE ARMED FORCES? _TK!091! Yes _TK!092! No




Specialty TK!093! Date Entered TK!094! Discharge Date TK!095!



3825 85th Avenue North

Brooklyn Park, MN 55443

Tel. (763) 425-8822 * Fax. (763) 425-5636




3825 85th Avenue North

Brooklyn Park, MN 55443

Tel. (763) 425-8822 * Fax. (763) 425-5636

APPLICATION FOR EMPLOYMENT




Work Experience

Please list your work experience for the past five years beginning with your most recent job held.
If you were self-employed, give firm name.
Attach additional sheets if necessary.







Name of employer TK!096!


Address TK!097!

Name of last supervisor

TK!100!

Employment dates

From

TK!101!

Pay or salary

Start

TK!103!

City, State, Zip Code TK!098!


Phone number TK!099!




To

TK!102!

Final

TK!104!




Your last job title TK!105!

Reason for leaving (be specific) TK!106!

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

TK!107!




Name of employer TK!108!


Address TK!109!

Name of last supervisor

TK!112!

Employment dates

From

TK!113!

Pay or salary

Start

TK!115!

City, State, Zip Code TK!110!


Phone number TK!111!




To

TK!114!

Final

TK!116!




Your Last Job Title TK!117!

Reason for leaving (be specific) TK!118!

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

TK!119!







Name of employer TK!120!


Address TK!121!

Name of last supervisor

TK!124!

Employment dates

From

TK!125!

Pay or salary

Start

TK!127!

City, State, Zip Code TK!122!


Phone number TK!123!




To

TK!126!

Final

TK!128!




Your last job title TK!129!

Reason for leaving (be specific) TK!130!

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

TK!131!





3825 85th Avenue North

Brooklyn Park, MN 55443

Tel. (763) 425-8822 * Fax. (763) 425-5636




3825 85th Avenue North

Brooklyn Park, MN 55443

Tel. (763) 425-8822 * Fax. (763) 425-5636

APPLICATION FOR EMPLOYMENT




May we contact your present employer? _TK!132! Yes _TK!133! No

Did you complete this application yourself _TK!134! Yes _TK!135! No

If not, who did? _TK!136!

The position being applied for may require lifting of 1-50 lbs. Will you be able to perform these job functions with or without a reasonable accommodation? _TK!182! Yes _TK!183! No

PLEASE READ CAREFULLY

APPLICATION FORM WAIVER

In exchange for the consideration of my job application by Ceres Environmental Services, Inc., I agree that: Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of Ceres Environmental Services, Inc., or otherwise to change in any respect the employment "at-will" relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the President of the Company. Both the undersigned and Ceres Environmental Services, Inc. may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits.

I understand that, in connection with the routine processing of your employment application, the Company may procure a consumer report and/or an investigative consumer report on me. A consumer reporting agency may be utilized to obtain the report for the Company. The report my contain information bearing my character, general reputation, personal characteristics, mode of living, and credit standing. Information that may be obtained include, but are not limited to: credit reports, social security number verification, criminal records checks, verification of employment positions held, personal and professional references checks, and licensing and certification checks. Upon written request from me, the Company will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act.

I also understand that if I am applying for a position which a Commercial Driver’s License Class A is required and the Ceres Environmental Services, Inc. offered me a job, it may be conditioned on the result of a physical examination, drug and alcohol test.

I further understand that my employment with the Company shall be probationary for a period of ninety (90) days, and further that at any time during the probationary period or thereafter, my employment relation with the Company is terminable at will for any reason by either party.

I certify that all facts contained in the application and my resume, if submitted, are true and complete. I acknowledge that the company is relying on the accuracy of the information I am providing. I also understand that if this information is found to be incomplete, inaccurate or that I have made a misrepresentation or omission of any information, that this will be grounds to disqualify me from consideration for employment, or disciplinary action up to and including termination should I obtain employment.

I understand that completion of this Application For Employment does not guarantee that I have been employed by Ceres. This application for employment is good for 30 days only. Consideration for employment after 30 days requires a new application.

By signing below you state that you understand the application:

Signature of applicant __TK!137!__(Digitally Signed) Date: _TK!138!

This Company is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications.

Thank you for completing this application form and for your interest in our business.



CONFIDENTIAL
Background Check Authorization

Print Name: _TK!139! TK!140! TK!141!

(First) (Middle) (Last)

Former Name(s) and Dates Used: TK!142!

Current Address Since: _TK!143! TK!144! TK!145! TK!146!

(Mo/Yr) (Street) (City) (Zip)

Previous Address From: _TK!147! TK!148! TK!149! TK!150!

(Mo/Yr) (Street) (City) (Zip)

Previous Address From: _TK!151! TK!152! TK!153! TK!154!

(Mo/Yr) (Street) (City) (Zip)
Social Security Number: TK!155! Date of Birth: TK!156!

Telephone Number: TK!157!

Driver’s License Number/State: TK!158! / TK!159!
I hereby authorize Ceres Environmental Services, Inc. and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for employment and/or volunteer purposes. I understand that the scope of the consumer report/investigative consumer report may include, but is not limited to the following areas: credit reports, social security number verification, criminal records checks, verification of employment positions held, education background, current and previous residences, drug testing, civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions, driving records, birth records, personal and professional references checks, and licensing and certification checks. Upon written request from me, the Company will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act.
I further authorize any individual, company, firm, corporation, or public agency (including the Social Security Administration and law enforcement agencies) to divulge any and all information, verbal or written, pertaining to me, to Ceres Environmental Services, Inc. or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or date received from other sources.
I further understand that if applying for a position which is subject to the United States Department of Transportation, Federal Motor Carrier Safety Administration such as requiring a Commercial Driver’s License Class A, B, or C, I will be subjected to a physical examination, drug and alcohol test. I hereby authorize such examinations to be conducted by Ceres Environmental Services, Inc. or its agents.
I hereby release Ceres Environmental Services, Inc., the Social Security Administration, and its agents, officials, representative, or assigned agencies, including officers, employees, or related personnel both individually and collectively, from any and all liability for damages of whatever kind, which may, at any time, result to me, my heirs, family, or associates because of compliance with this authorization and request to release.

Signature: __TK!137! (Digitally Signed) Date: _TK!138!



Voluntary Affirmative Action Information

It is the policy of Ceres Environmental Services, Inc., to provide equal employment opportunities to all qualified applicants and employees regardless of race, religion, color, sex, age, national origin, marital status, disability, special disabled veteran or Vietnam era veteran status.

Your completion of the information below is entirely voluntary. This information is requested solely to enable Ceres to meet recordkeeping and affirmative action requirements under Executive Order 11246, as amended, Section 402 of the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, Section 503 of the Rehabilitation Act of 1973, as amended, and the Americans with Disabilities Act. The information will be kept in strictest confidence.

Return this form to Human Resources. This information will not become a part of your personnel file. Inclusion or exclusion of any of the data will not affect any employment decision.

Position(s) Applied For: TK!160! Date: _TK!138!

Name (please print): _TK!137! Gender (check one): _TK!161! Male _TK!162! Female

Race/Ethnic Group (check one):

TK!163! White: (not of Hispanic origin) A person with origins in any of the original peoples of Europe, North Africa, or the Middle East who is not of Hispanic origin.

TK!164! Black or African American: (not of Hispanic origin) A person with origins in any of the black racial groups of Africa who is also not of Hispanic origin.

TK!165! Hispanic: A person of Mexican, Puerto Rican, Cuban, South American, or other Spanish culture or origin, regardless of race.

TK!166! Asian: A person with origins in any of the original people of the Far East, Southeast Asia, the Indian Subcontinent, including, Cambodia China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

TK!167! American Indian or Alaskan Native: A person with origins in any of the original peoples of North or South American and who maintains ultural identification through tribal affiliation or community attachment.

TK!168! Native Hawaiian or Other Pacific Islander: A person with origins in any of the Peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

TK!169! Two or more races: A person who identifies with more than one of the above races.

Disabled Veterans: TK!170! Yes TK!171! No

(i) 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 (ii) a person who was discharged or released from active duty because of a service-connected disability.
Other Protected Veterans: TK!172! Yes TK!173! No

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.
Armed Forces Service Medal Veterans: TK!174! Yes TK!175! No

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 medal was awarded pursuant to Executive Order 12985 (61 Fed. Reg. 1209).
Recently Separated Veteran: TK!194! Yes TK!195! No

A 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.
3825 85th Avenue North | Brooklyn Park, Minnesota 55443 | OFFICE 763.425.8822 | TOLL-FREE 800.218.4424 | FAX 763.425.5636 ceresenvironmental.com



Human Resources Department

EMERGENCY CONTACT FORM



Name: _TK!188!

Social Security #: _TK!189!

Address: _TK!190!

_TK!191!

____________________________________________________

Phone Number : _TK!192!

Date Of Birth: _TK!193!

Date of Hire: _________________________________________________

In case of Emergency, person to contact:

Name: _TK!184!

Phone Number: _TK!185!

Additional Number: _TK!186!

Relation: _TK!187!

TK!999!

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