PERSONAL PHYSICAL AND HEALTH DATA EDUCATION - Dap

AN EQUAL OPPORTUNITY EMPLOYER
PERSONAL
NAME (LAST) (FIRST) (FULL MIDDLE NAME)
CURRENT ADDRESS CITY, STATE, ZIP CODE PHONE NUMBER
FOR WHAT POSITION ARE YOU APPLYING?
DATE AVAILABLE FOR EMPLOYMENT
ARE YOU WILLING TO RELOCATE? YES NO
ARE YOU WILLING TO TRAVEL IF REQUIRED?
GEOGRAPHIC PREFERENCE
HAVE YOU EVER BEEN EMPLOYED BY DAP BEFORE?
YES
INDICATE LOCATIONS AND DATES
NO
YES
NO
HAVE YOU EVER BEEN CONVICTED OF A FELONY OR ACT OF DISHONESTY, THEFT, OR VIOLENCE?
FROM FURTHER CONSIIDERATION.
REVEALING A CONVICTION WILL NOT AUTOMATICALLY DISQUALIFY YOU
YES NO IF YES, EXPLAIN
HOW WERE YOU REFERRED TO US? (PLEASE CHECK)
SCHOOL – NAME OF SCHOOL: ADVERTISEMENT – NAME OF PUBLICATION: WEBSITE:
EMPLOYEE – NAME OF EMPLOYEE: EMPLOYMENT AGENCY – NAME OF AGENCY: OTHER – SPECIFY:
MILITARY SERVICE (BRANCH) (DATES OF SERVICE))
PHYSICAL AND HEALTH DATA
ANY OFFERS OF EMPLOYMENT WILL BE CONTINGENT UPON THE RESULTS OF A POST OFFER PRE-EMPLOYMENT DRUG SCREEN.
EDUCATION
SCHOOL LEVEL SCHOOL NAME AND ADDRESS NO. OF YEARS
ATTENDED
HIGH SCHOOL
DID YOU
GRADUATE?
MAJOR SUBJECT OR COURSE OF STUDY
VO-TECH, BUSINESS
OR TRADE SCHOOL
COLLEGE
GRADUATE SCHOOL
Revised 1/25/13

REFERENCES
NAME PHONE OCCUPATION YEARS
KNOWN
PREVIOUS EMPLOYMENT
1.EMPLOYER FROM (DATE) TO (DATE)
PHONE WORK PERFORMED DISCIPLINARY ACTIONS RECEIVED
ADDRESS
JOB TITLE
SUPERVISOR
REASON FOR LEAVING
SALARY
2.EMPLOYER FROM (DATE) TO (DATE)
PHONE WORK PERFORMED DISCIPLINARY ACTIONS RECEIVED
ADDRESS
JOB TITLE
SUPERVISOR
REASON FOR LEAVING
SALARY
3.EMPLOYER FROM (DATE) TO (DATE)
PHONE WORK PERFORMED DISCIPLINARY ACTIONS RECEIVED
ADDRESS
JOB TITLE
SUPERVISOR
REASON FOR LEAVING
SALARY
MAY WE CONTACT YOUR CURRENT EMPLOYER? YES NO
EMPLOYMENT
SUMMARIZE SPECIAL SKILLS AND QUALIFICATIONS ACQUIRED FROM EMPLOYMENT OR OTHER EXPERIENCE
INDICATE ANY FOREIGN LANGUAGES THAT YOU SPEAK, READ OR WRITE THAT ARE RELATED TO THE POSITION FOR WHICH YOU
ARE APPLYING.
Revised 1/25/13

NOTE: IF HIRED, YOU MUST COMPLETE THE I-9 FORM REQUIRED BY THE US IMMIGRATION AND NATURALIZATION SERVICE,
SHOWING YOUR IDENTITY AND ELIGIBILITIY TO WORK IN THE UNITED STATES NO LATER THAN THREE BUSINESS DAYS AFTER YOUR
DATE OF HIRE.
ALL TERMS, CONDITIONS AND BENEFITS OF EMPLOYMENT, WHETHER ENUMERATED HERE OR ELSEWHERE, ARE UNILATERAL
EXPRESSIONS OF CURRENT POLICY AND, WITH THE EXCEPTION OF EMPLOYMENT-AT-WILL STATUS, MAY BE CHANGED AT ANY TIME
AND FOR ANY REASON WITH OR WITHOUT NOTICE AT THE COMPANY’S DISCRETION. NOTHING CONTAINED HERE IS INTENDED TO
CREATE AN EMPLOYMENT CONTRACT, EXPRESS OR IMPLIED, BETWEEN THE COMPANY AND ITS EMPLOYEES. NO VESTING OF
“RIGHTS” EXPRESS OR IMPLIED IS INTENDED.
IF EMPLOYED, I AGREE THAT I WILL KEEP TRADE SECRETS AND CONFIDENTIAL INFORMATION IN THE STRICTEST CONFIDENCE,
WITHOUT DISCLOSURE TO ANY OTHER PERSON(S) DURING AND AFTER THE TERM OF MY EMPLOYMENT. I WILL PERFORM ANY ACTS
DEEMED NECESSARY BY THE CORPORATION OR ANY OF ITS SUBSIDIARIES TO PROTECT RIGHTS TO SUCH TRADE SECRETS AND
CONFIDENTIAL INFORMATION, AND I WILL NOT COMPETE WITH THE CORPORATION OR ANY OF ITS SUBSIDIARIES IN ANY WAY,
DIRECTLY OR INDIRECTLY, DURING THE TERM OF MY EMPLOYMENT.
I FURTHER AGREE AND UNDERSTAND ANY FALSE STATEMENT, MISREPRESENTATION OR OMISSIONS OF FACT CONCERNING MY
RESPONSES TO THIS APPLICATION OR OTHER INQUIRIES MADE ABOUT MY APPLICATION, INCLUDING WITHOUT LIMITATION
RESPONSES GIVEN IN ANY INTERVIEW IN WHICH I MIGHT BE ASKED TO PARTICIPATE, SHALL CONSTITUTE SUFFICIENT GROUNDS
FOR REJECTION OF MY APPLICATION OR TERMINATION FROM EMPLOYMENT AS APPLICABLE.
BY SIGNING THIS APPLICATION, I UNDERSTAND THAT ANY EMPLOYMENT I MIGHT BE OFFERED SHALL BE AT WILL. I UNDERSTAND
THAT IF I AM EMPLOYED BY DAP, THAT EMPLOYMENT MAY BE TERMINATED AT ANY TIME WITHOUT CAUSE BY EITHER ME OR THE
COMPANY. I FURTHER UNDERSTAND THAT NOTHING IN THIS APPLICATION OR ANY COMMUNICATIONS MADE TO ME BY DAP OR ITS
REPRESENTATIVES IS INTENDED TO CREATE OR DOES CREATE ANY CONTRACT OF EMPLOYMENT. IF EMPLOYED, I FURTHER AGREE
TO ABIDE BY THE RULES AND REGULATIONS OF THE COMPANY, AND I UNDERSTAND THAT THE COMPANY RESERVES THE RIGHT TO
ADD TO OR MODIFY OR DELETE RULES AND REGULATIONS FROM TIME TO TIME AS IT DEEMS APPROPRIATE IN ITS SOLE
DISCRETION.
I UNDERSTAND THAT THIS APPLICATION WILL BE CONSIDERED FOR A PERIOD NOT TO EXCEED 90 DAYS. I UNDERSTAND THAT IF I
HAVE NOT BEEN OFFERED A POSITION DURING THIS PERIOD, IT WILL BE NECESSARY FOR ME TO SUBMIT A NEW APPLICATION TO
BE CONSIDERED FOR FUTURE POSITIONS BEYOND THIS TIME.
INVESTIGATIVE CONSUMER REPORT
IN MAKING THIS APPLICATION FOR EMPLOYMENT, IT IS UNDERSTOOD THAT AN INVESTIGATION MAY BE MADE WHEREBY
INFORMATION IS OBTAINED THROUGH, AMONG OTHER METHODS, PERSONAL INTERVIEWS WITH YOUR CO-WORKERS, FRIENDS AND
OTHERS WITH WHOM YOU ARE ACQUAINTED. THIS INVESTIGATION INCLUDES INQUIRIES AS TO JOB SKILLS, ABILITIES, PAST AND
CURRENT WORK PERFORMANCE, AND ANY OTHER MATTER RELATED TO THE SCOPE AND NATURE OF THE JOB APPLIED FOR. AS
APPLICANT, I HOLD HARMLESS ANY AND ALL PARTIES, INCLUDING THE COMPANIES WHO ARE INVOLVED IN THE PROCESS OF
CHECKING REFERENCES. I HEREBY AUTHORIZE ALL PERSONS AND SOURCES, INCLUDING CREDIT BUREAUS, DEEMED NECESSARY
BY THE COMPANY TO SUPPLY INFORMATION CONCERNING MY BACKGROUND AND RELEASE THEM FROM ANY LIABILITY AND
RESPONSIBILITY ARISING FROM THEIR DOING SO.
DATE
APPLICANT SIGNATURE
MARYLAND POLYGRAPH STATUTE
UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE
EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A LIE DETECTOR OR SIMILAR TEST. AN
EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $100.
APPLICANT
PRINT NAME
Revised 1/25/13