Phone: (562) 907-6700 Fax: (562) 907-6701

employment@ORConceptsApplied.com

OR Concepts Applied

Application For Employment

PRINT IN BLACK INK OR TYPE. These instructions must be followed exactly. Fill out application form completely. If questions are not applicable, enter “NA”. Do not leave questions blank. Be sure to sign when completed. OR Concepts Applied is an Equal Opportunity Employer and does not discriminate on the basis of race, color, national origin, sex, religion, age, or disability. You may make copies of this application and enter different position titles, but each copy must have an original signature. Resumes can be attached to the application.

Date Of Application: __________________

Name___________________________________________________________ Social Security Number: ______-____-______

(Last) (First) (Middle)

Mailing Address (Current)_____________________________________________________________ ( ) -

(Street) (City) (State) (Zip) (Daytime Phone)

Email Address: ______________________________________________

List any other names used if different from name given on this application.

List Exact Title Of Position Or Type Of Work For Which You Wish To Apply:

Job Posting No: (If applicable)

List Other Positions Or Types of Work That Interest You:

Full-Time Part-Time Summer Temp/Project Date available for work:

Are you willing to travel? Yes No If yes, what percent of time?

Annual Salary Requirements: $_______________

EDUCATION:

Starting from most recent, list all education completed: Note: Applicants may be required to provide proof of diploma, degree, transcripts, licenses, certifications and registrations.)

Years of Undergraduate / Graduate Education: 1 2 3 4 5 6 7 8 9 10+ Associate Bachelor Master Doctoral

Type of

Dates Attended

Sem./Qtr.

Graduated

Expected

Type of

Major/Minor

School

Name and Location of School

From

Units

Graduation

GPA

Diploma or

Field of

Mo.

Yr.

Mo.

Yr.

Completed

Yes

Date

Degree

Study

High School

Undergraduate

Colleges or

Universities

Graduate

Schools

Technical,

Vocational, or

Business

Schools

If you expect to complete an educational program in the near future, please indicate what type of degree or program and expected completion date:

Degree/Program: ____________________________ Expected Date of Completion: ___________________

List professional license, certificate, or other credentials related to the position for which you are applying, complete the following:

License/Certification

Date Issued

Issued by (State / Authority)

License No.

Location of Issuing Authority (city & state)

SPECIAL SKILLS/QUALIFICATIONS:

List all knowledge, special skills and abilities that best demonstrate your qualifications for this position. Include technical skills, programming languages, engineering, teaching, and other special experiences, job related honors, computers or office equipment, software programs and hardware, etc.

GENERAL:

Do you have United States citizenship? Yes No

Are you legally eligible for employment in the United States? Yes No

Have you ever been convicted of a law violation(s), felony, including moving traffic violations? Yes No If your answer is “Yes,” explain in concise detail on a separate sheet of paper, giving the dates and nature of the offense, the name and location of the court, and the disposition of the case. A conviction may not disqualify you, but a false statement will. Note: In some cases we may require additional information related to convictions of misdemeanors and deferred adjudication.

How did you learn about this employment opportunity?_________________________________________________________

SECURITY CLEARANCE:

Have you ever had a government security clearance? Yes No

If Yes, list the type of clearance _________ Agency ________ Date of clearance from _________ to _________

Is your clearance currently active? Yes No Date of last update __________

MILITARY SERVICE: (A copy of a report of separation from the Armed Services may be required.)

Have you ever served in the Armed Forces of the United States? Yes No

Air Force Army Navy Marine Corps National Guard Marine Corps Other Service List: _______________

Number Years of Service: _________ Grade/Rank: ____________

Dates of Service (From/To):

Do you claim veterans’ preference? Yes No

EMPLOYMENT HISTORY:

This information will be the official record of your employment history and must accurately reflect all significant duties performed. Summaries of experiences should clearly describe your qualifications.

1. Include ALL relevant employment. Begin with your current or last position and work back to your first position.

2. Employment history should include each position held, even those with the same employer.

3. Give a brief summary of the technical and, if appropriate, the managerial responsibilities of each position you have held.

4. For supervisory/managerial positions, indicate the number of employees you supervised.

If you need additional space to adequately describe your employment history, you may copy this employment history sheet or attach a typed employment history providing the same information in the same format as this application form.

May we contact your current employer? Yes No If yes, initial:_____________

Position Title:								Immediate Supervisor	Full- Time
Employer:								Name	Part-Time
Mailing Address:									Summer
City and State/Zip:								Title	Temp/Project
Employer’s Telephone No: ( )								Supervisor’s Telephone No.	Give average
Starting Date Leaving Date						Hourly Rate	Technical	( )	number of hours
Mo.	Day	Yr.	Mo.	Day	Yr.		Non-managerial	If supervisory,	worked per week
							Supervisory/Managerial	number of employees you supervised	if part-time
Summary of experience:
Specific reason for leaving:

Position Title:								Immediate Supervisor	Full- Time
Employer:								Name	Part-Time
Mailing Address:									Summer
City and State/Zip:								Title	Temp/Project
Employer’s Telephone No: ( )								Supervisor’s Telephone No.	Give average
Starting Date Leaving Date						Hourly Rate	Technical	( )	number of hours
Mo.	Day	Yr.	Mo.	Day	Yr.		Non-managerial	If supervisory,	worked per week
							Supervisory/Managerial	number of employees you supervised	if part-time
Summary of experience:
Specific reason for leaving:

Position Title:								Immediate Supervisor	Full- Time
Employer:								Name	Part-Time
Mailing Address:									Summer
City and State/Zip:								Title	Temp/Project
Employer’s Telephone No: ( )								Supervisor’s Telephone No.	Give average
Starting Date Leaving Date						Hourly Rate	Technical	( )	number of hours
Mo.	Day	Yr.	Mo.	Day	Yr.		Non-managerial	If supervisory,	worked per week
							Supervisory/Managerial	number of employees you supervised	if part-time
Summary of experience:
Specific reason for leaving:

PROFESSIONAL REFERENCES

Provide a minimum of three (3) professional references. Additional references can be provided on separate sheets of paper.

Note: I authorize any of the persons or organizations referenced in this application to give you any and all information concerning my previous employment, education, or any other information they might have, personal or otherwise, with regard to any of the subjects covered by this application, and I release all such parties from all liability from any damages which may result from furnishing such information to you.

May we contact your references? Yes No If yes, initial:_____________

Reference Name:

Employed By:

Contact Address:

City and State/Zip:

Reference Telephone No: ( )

Reference Name:

Employed By:

Contact Address:

City and State/Zip:

Reference Telephone No: ( )

Reference Name:

Employed By:

Contact Address:

City and State/Zip:

Reference Telephone No: ( )

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY AND INDICATE YOUR UNDERSTANDING

AND ACCEPTANCE BY SIGNING IN THE SPACE PROVIDED

1. I certify that all the information provided by me in connection with my application, whether on this document or not, is true and complete, and I understand that any misstatement, falsification, or omission of information shall be grounds for refusal to hire or, if hired, termination.

2. I understand that as a condition of employment, I will be required to provide legal proof of authorization to work in the U.S.

3. I understand that some in some cases it will be required to check any background criminal history in accordance with applicable federal and state statutes.

4. I authorize any of the persons or organizations referenced in this application to give you any and all information concerning my previous employment, education, or any other information they might have, personal or otherwise, with regard to any of the subjects covered by this application, and I release all such parties from all liability from any damages which may result from furnishing such information to you.

Applicant Signature:_______________________________________ Date: __________

Mail or Fax To:

OR Concepts Applied

7032 Comstock Ave, Suite 100

Whittier, CA 90602

For Company Use Only

EMPLOYMENT HISTORY:

PROFESSIONAL REFERENCES