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First Name*
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Middle Name
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Last Name*
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Present Address & Contact Information
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No & Street
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City
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State
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ZIP
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Business Phone
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Home Phone
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Mobile Phone
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Email*
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Employment Desired
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Position Applying For
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Personal Information
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Have you ever applied to or worked for Clark Pacific before?
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Yes
No
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If Yes, When?
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Do you have any friends or relatives working for Clark Pacific?
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Yes
No
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If Yes, state name(s) and relationship:
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Are you at least 18 years old?
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Yes
No
(If under 18, hire is subject to verification that you are of minimum legal age.)
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If hired, can you present evidence of your U.S. citizenship or proof of your legal right to live and work in this country?
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Yes
No
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If hired, would you have a reliable means of transportation to and from work?
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Yes
No
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Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation?
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Yes
No
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If no, describe the functions that cannot be performed: |
(Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Hire may be subject to passing a medical examination, and to skill and agility tests.)
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Have you ever been convicted of a criminal offense (felony or serious misdemeanor)?
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Yes
No
(Misdemeanor convictions for marijuana-related offenses that are more than two years old need not be listed.)
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If yes, state nature of the crime(s), when and where convicted, and disposition of the case (attach a separate page if necessary)
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(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)
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| Education, Training & Experience |
| High School |
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Name
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No of Years Completed
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Did you Graduate?
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Yes
No
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Diploma
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GPA
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| College / University |
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Name
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No of Years Completed
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Did you Graduate?
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Yes
No
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Diploma
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GPA
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| Vocational / Business School |
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Name
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No of Years Completed
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Did you Graduate?
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Yes
No
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Diploma
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GPA
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| Professional Designations |
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Are you a licensed Professional Engineer?
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Yes
No
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Do you have your EIT?
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Yes
No
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| Employment History |
| List below all present and past employment starting with your most recent employer (last five years is sufficient). Account for all periods of unemployment. |
| Employer 1 |
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Company Name
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Telephone
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Type of Business
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Supervisor's Name
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Street Address
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City
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State
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Zip
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Date Hired
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Date Left
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Weekly Pay, Starting
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Weekly Pay, Ending
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Position and Duties
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Reason for Leaving
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May we contact this employer for a reference?
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Yes
No
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| Employer 2 |
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Company Name
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Telephone
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Type of Business
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Supervisor's Name
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Street Address
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City
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State
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Zip
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Date Hired
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Date Left
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Weekly Pay, Starting
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Weekly Pay, Ending
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Position and Duties
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Reason for Leaving
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May we contact this employer for a reference?
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Yes
No
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| Employer 3 |
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Company Name
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Telephone
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Type of Business
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Supervisor's Name
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Street Address
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City
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State
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Zip
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Date Hired
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Date Left
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Weekly Pay, Starting
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Weekly Pay, Ending
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Position and Duties
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Reason for Leaving
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May we contact this employer for a reference?
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Yes
No
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| References |
| Reference 1 |
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First Name
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Last Name
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Telephone No
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Email Address
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Address & Street
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City
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State
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ZIP
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Occupation
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Number of Years Acquainted
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| Reference 2 |
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First Name
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Last Name
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Telephone No
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Email Address
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Address & Street
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City
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State
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ZIP
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Occupation
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Number of Years Acquainted
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| Reference 3 |
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First Name
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Last Name
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Telephone No
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Email Address
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Address & Street
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City
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State
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ZIP
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Occupation
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Number of Years Acquainted
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| Representations |
| READ CAREFULLY AND CHECKMARK EACH PARAGRAPH BELOW |
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I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.
I have read and understood this paragraph
I hereby authorize Clark Pacific to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the references I have listed to disclose to the company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the Company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.
I have read and understood this paragraph
I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and the Company. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or the Company, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the Company's designated representative.
I understand that any offer of employment is contingent upon the successful passing of a drug test.
I have read and understood this paragraph
Should a search of public records (including records documenting an arrest, indictment, conviction, civil judicial action, tax lien or outstanding judgment) be conducted by internal personnel employed by the Company, I am entitled to copies of any such public records obtained by the Company unless I mark the check box below. If I am not hired as a result of such information, I am entitled to a copy of any such records even though I have checked the box below.
I have read and understood this paragraph
I waive receipt of a copy of any public record described in the paragraph above.
I have read and understood this paragraph
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| Pre-Employment EEO Data Form |
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Clark Pacific provides equal employment opportunity to all qualified applicants and employees by prohibiting discrimination against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, marital status, national origin, age, veteran status or disability.
This information will be used solely to assist us in complying with Federal and State Equal Employment Opportunity and Affirmative Action record keeping requirements. Refusal to provide this information will not adversely affect you.
PLEASE NOTE: This form is NOT a part of your official application for employment. This information will be recorded and maintained in a confidential file, separate from all other records.
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| Applicant Information |
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SSN
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Sex
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Male
Female
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| Ethnicity |
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More specific ethnicity information is required for filing EEO-1 reports. Please check the appropriate Equal Opportunity Identification Group. You should only check one of the following ethnicity or race categories:
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Race:
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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.
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.
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) – A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
American Indian or Alaska Native (Not Hispanic or Latino) – A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.
If you would like to identify as two or more races, please check Two or More Races below, in addition to your one selection above.
Two or More Races (Not Hispanic or Latino)
I choose not to disclose
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Comments:
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| Challenge Question |
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Please provide a whole number answer to the following math problem to help us defend against robot requests. We appreciate your help!
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