Jobs Application

General Information

First Name *

Middle Name *

Last Name *

Home Address *

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Home Phone *

Business Phone

Are you under 18? *

If yes, what is your date of birth?

Are you either: (1) a U.S. citizen or, if not (2) do you currently have lawful employment authorization that permits you to work for the Company without the Company having to take any action, either upon employment, or at any date in the future, to ensure or assist you in maintaining lawful employment authorization to work for the Company? *

If your answer was “Yes,” answer the following question: Are you a student on a temporary visa? Proof of authorization to work will be required if you are employed by Patz Corporation.

Role & Availability

Position Desired *

Pay Expected *

When are you available to begin work? *

Are you available for full-time work? *

If not, how many hours per week can you work?

Special training or skills (languages, machine operation, etc.) *

Will you work overtime if asked? *

Are you currently on lay-off and subject to call back? *

Have you filed an application here before? *

if yes, when?

Have you ever worked here before? *

if yes, when?

(1) Have you ever been convicted of, plead nolo contendere (no contest) to, or been fined in connection with any felony, misdemeanor, municipal ordinance violation, or any other type of offense (other than a parking ticket), regardless of the nature of the penalty or fine for that offense? *

(If you are in doubt about the nature of any offense, please list; this question is designed to require disclosure of all past convictions, violations, fines or offenses, and the failure to list a conviction, offense, violation or fine will be considered falsification and will be grounds for refusal to hire or termination of employment. However, no application will be denied a position because of past conviction, offense, violation or fine, which is not substantially related to the circumstances of the employment sought.)

If Yes, provide details

(2) Are you currently subject to a pending criminal charge for any misdemeanor or felony? *

(If you are in doubt about the nature of any offense, please list; this question is designed to require disclosure of all past convictions, violations, fines or offenses, and the failure to list a conviction, offense, violation or fine will be considered falsification and will be grounds for refusal to hire or termination of employment. However, no application will be denied a position because of past conviction, offense, violation or fine, which is not substantially related to the circumstances of the employment sought.)

If Yes, provide details

Education

College Name

Did you Graduate?

Course of Study

Degree or Diploma?

Years Completed

High School Name *

Did you Graduate? *

Course of Study *

Degree or Diploma? *

Years Completed *

Elementary School Name *

Did you Graduate? *

Course of Study *

Degree or Diploma? *

Years Completed *

Military Experience

Complete this section if you served in the U.S. Armed Forces

Describe your duties and any special training

Branch of service

Rank at discharge

Work History

Please give accurate, complete full-time and part-time employment record. Start with present or most recent employer.

Company Name

Company Phone Number

Company Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

May we contact this employer to verify your employment?

If no, why?

Employment Start & End Dates

If still working for company please list start date through "present"

Supervisor Name

Job Title Held

Starting Hourly Pay

Please note salary or hourly.

Most Recent Pay

Please note salary or hourly.

Reason for leaving

Company Name

Company Phone Number

Company Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

May we contact this employer to verify your employment?

If no, why?

Employment Start & End Dates

If still working for company please list start date through "present"

Supervisor Name

Job Title Held

Starting Hourly Pay

Please note salary or hourly.

Most Recent Pay

Please note salary or hourly.

Reason for leaving

Company Name

Company Phone Number

Company Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

May we contact this employer to verify your employment?

If no, why?

Employment Start & End Dates

If still working for company please list start date through "present"

Supervisor Name

Job Title Held

Starting Hourly Pay

Please note salary or hourly.

Most Recent Pay

Please note salary or hourly.

Reason for leaving

Agreement

I certify answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand that this application is not and is not intended to be a contract of employment. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I can be assigned to another shift and that I am required to abide by all rules and regulations of the Corporation

Signature *

Date / Time *

Please Upload Your Resume

File Upload

Drop your file here or click here to upload You can upload up to 2 files.

References

Reference Name

Reference Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Home Phone

Work Phone

Relationship

What's the Best Time to Contact this Person (CST)?

Are they available between 6:30 a.m. - 4:30 p.m. CST?

Is it okay to contact this person at work?

Reference Name

Reference Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Home Phone

Work Phone

Relationship

What's the Best Time to Contact this Person (CST)?

Are they available between 6:30 a.m. - 4:30 p.m. CST?

Is it okay to contact this person at work?

Reference Name

Reference Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Home Phone

Work Phone

Relationship

What's the Best Time to Contact this Person (CST)?

Are they available between 6:30 a.m. - 4:30 p.m. CST?

Is it okay to contact this person at work?

Release of Information Authorization

I hereby authorize the addressed company/individual to furnish Patz Corporation, Pound, Wisconsin with the information requested, and do hereby release the addressed company or individual, including Patz Corporation, from all liability for any damage whatsoever incurred in furnishing such information.

Signature *

Date / Time *

Voluntary Affirmative Action Information

In an effort to implement our voluntary government affirmative action program record keeping and reporting requirements, we ask that you complete this data survey. Your cooperation is appreciated. Providing this information is STRICTLY VOLUNTARY. Failure to provide it will not subject you to discharge or discipline or any other negative personnel action. Information provided will be kept confidential in accordance with applicable regulations.

Name

Gender

Position Applied For

Select one of the following boxes:

Hispanic or Latino: a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
White (not Hispanic or Latino): a person having origins in any of the original peoples of Europe, the Middle East, or North Africa
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 original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
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
American Indian or Alaska Native (not Hispanic or Latino): a person having origins in any of the original peoples or North or South America (including Central America), and who maintains tribal affiliation or community attachment.
Two or More Races (not Hispanic or Latino): all persons who identify with more than one of the races of White, Black or African American, Native Hawaiian or Other Pacific Islander, Asian, or American Indian or Alaska Native.
Decline to identify

Invitation to self-identify protected veteran status

This employer, Patz Corporation, 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:

A “disabled veteran” is one of the following: (a) a veteran 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 (b) 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.

If you believe you belong to any of the categories of protected veterans listed above, 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.

Voluntary Identification of Disability

Please review the information from provided on this pdf form and answer the following question:

Please select one of the following

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 do not want to answer

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Patz Employment Application

General Information

Role & Availability

Education

Military Experience

Work History

Agreement

Please Upload Your Resume

References

Release of Information Authorization

Voluntary Affirmative Action Information

Voluntary Identification of Disability

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