Personal Information:

Date:   Social Security:

First Name:MI:

Last Name:

Address:

City:State: AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MO MT MS NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY AE AA AP Zip:

Home Phone:Cell Phone:Pager:Email:

Message Phone:

Email:

Pay Expected:Location:

Do you have transportation? Yes No Will you work overtime? Yes No

How did you hear about First Diversity?

What position are you applying for?

Are you legally eligible for work in the United States? Yes No Are you at least 18 years of age? Yes No

Can you perform the essential functions of the job you are applying for? Yes No

Have you ever been convicted of a felony? No Yes   (Conviction is not an automatic bar to employment.)

Emergency Contact:

Address:

Phone:Relationship:

Education Information:

1-6  Jr. HS  High School   College  Other 

Name of School (Highest Level):

Degree Earned:

Other Education/Certifications:

Location of School:GPA:

Job History:

Begin with your most recent employer.

Dates of Employment: FromTo

Employer Name:OK to Contact? Yes No

Position:

Supervisor:

Location:Phone:

Starting Pay:Ending Pay:

Job Duties:

Reason For Leaving:

Dates of Employment: FromTo

Employer Name:OK to Contact? Yes No

Position:

Supervisor:

Location:Phone:

Starting Pay:Ending Pay:

Job Duties:

Reason For Leaving:

Dates of Employment: FromTo

Employer Name:OK to Contact? Yes No

Position:

Supervisor:

Location:Phone:

Starting Pay:Ending Pay:

Job Duties:

Reason For Leaving:

Skills and Certifications:

Please check box if you are uploading your resume.

Additional Information:

Please Read Carefully and Check Acceptance Box To Sign Your Application.

1.  I certify that the information contained in this application is correct and I have not omitted any information.  I understand that falsification or omission of information may result in immediate dismissal.

2.  I understand and agree that in processing my employment application, First Diversity may request that an investigative consumer credit report be prepared which may include information as to my general reputation, past and present employment, police records, personal characteristics and mode of living.  I may request that First Diversity disclose to me the nature and scope of the investigation requested by written request to the personnel department within 10 days after I complete this application.  I also understand and agree that First Diversity may check my criminal history at any time, either before or after I am employed.

3.  I authorize the schools, references and prior employers listed above to provide my record, reason for leaving, and all other information they may have concerning me and I release all parties from liability or claims for damage whatsoever that may result therefrom. 

4.  I agree and acknowledge that only a First Diversity representative has the authority to make any oral or written agreements for employment for a specific time or condition of my employment.

5.  If hired, I agree and acknowledge that my employment can be terminated with or without cause or notice at any time by myself or First Diversity.

6.  If hired, I agree to abide by and conform to the rules and regulations of First Diversity which may be altered, modified, or changed at any time, with or without notice.

7.  I understand that if employed, that in consideration of employment and continued employment, I agree that any and all disputes or controversies arising during the period of my employment, including, but not limited to those resulting from discharge or layoff from employment, shall be submitted to binding arbitration in accordance with the rules of the American Arbitration Association, and that the arbitrator's award, if any, shall be binding on both parties, and that judgment upon the award rendered by the Arbitrator(s) may be in any court having jurisdiction thereof.  The expense of the arbitration shall be shared equally by the arbitrator or arbitrators; provided, that each party shall pay for and bear the cost of his or her own experts, evidence, and legal counsel.  Disputes which shall be subject to binding arbitration include, but are not limited to, any claims of discrimination on the basis of race, sex, religion, national origin, age, disability, whether state or federal, or any cause of action brought under the laws of the State of Ohio which laws shall govern all matters in dispute.

8.  I have been advised to consult with counsel before executing this application for employment.

9.  In order to be considered this application must be filled in completely.

10.  First Diversity is an equal opportunity employer.

I accept the above application and verify that all information is accurate and complete by submitting this form to First Diversity.