PERSONAL PHYSICAL AND HEALTH DATA EDUCATION - Dap

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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
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PERSONAL PHYSICAL AND HEALTH DATA EDUCATION - Dap

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