SPECTRA EMPLOYMENT APPLICATION LAST NAME FIRST NAME MIDDLE INITIAL POSITION APPLIED FOR PART-TIME OR FULL-TIME DATE COMPLETED SPECTRA IS AN EQUAL OPPORTUNITY EMPLOYER SPECTRA IT IS THE POLICY OF SPECTRA TO PROVIDE EQUAL EMPLOYMENT OPPORTUNITIES TO ALL INDIVIDUALS WITHOUT REGARD TO RACE, COLOR, RELIGION, CREED, GENDER, AGE, NATIONAL ORIGIN OR ANCESTRY, CITIZENSHIP, DISABILITY, SEXUAL ORIENTATION, MARITAL STATUS, VETERAN STATUS, OR ANY OTHER BASIS PROTECTED BY FEDERAL, STATE OR LOCAL LAWS. ALSO, TO THE EXTENT REQUIRED BY LAW, EQUAL EMPLOYMENT OPPORTUNITIES WILL BE PROVIDED TO ALL INDIVIDUALS REGARDLESS OF ANY PERCEPTION THAT THE INDIVIDUAL HAS A PROTECTED CHARACTERISTIC, OR ASSOCIATES WITH A PERSON WHO HAS OR IS PERCEIVED AS HAVING ANY PROTECTED CHARACTERISTICS. (Last Name) (First Name) (Middle Name) (Address) (City) (State) (Zip Code) (Telephone Number) (Email Address) Is there any other name under which you have employment or education records? ?Yes ? No If yes, indicate name records are listed under: Can you, within three (3) days after employment, submit documentation verifying that you are legally eligible to work in the United States? ? Yes ? No How did you learn about us? Are you related to any employee of the company? ? Yes ? No If yes, Name: Relationship: Have you ever worked for Spectra or any of our partner companies before? ?Yes ? No Date(s): to: Reason for Leaving: Position: Supervisor's name: Applicants under the age of 18 will not be considered for full-time employment. EDUCATION: (May or may not be considered depending on job applied for.) Describe any educational degrees, skills, training or experience you believe are relevant: Do you possess a High School diploma or GED certificate: ? Yes ? No College/University Degree Course of Study Number of years completed Graduate School Degree Course of Study Number of years completed SPECTRA DAYS AVAILABLE: (Check appropriate box) Sunday Monday Tuesday Wednesday Thursday Friday Saturday AM PM Are there any days, shifts or hours you will not work? ?Yes ? No If yes, please explain: Please list your minimum salary requirements: EMPLOYMENT HISTORY: Please complete for full time/part-time employment. Company Name: Telephone Number: ( ) Address: Dates Employed: to: Name of Supervisor: Job Title: Reason for leaving: May we contact? ? Yes ? No Company Name: Telephone Number: ( ) Address: Dates Employed: to: Name of Supervisor: Job Title: Reason for leaving: May we contact? ? Yes ? No Company Name: Telephone Number: ( ) Address: Dates Employed: to: Name of Supervisor: Job Title: Reason for leaving: May we contact? ? Yes ? No REFERENCES: Please list three (3) employment references. Please list at least one (1) supervisor. Name Organization/Company Name Telephone Name Organization/Company Name Telephone Name Organization/Company Name Telephone SPECTRA APPLICANT'S ACKNOWLEDGMENT (Please read carefully and sign.) I CERTIFY THAT THE INFORMATION I HAVE GIVEN HEREIN IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT ANY MISREPRESENTATION, OMISSIONS OF FACTS OR INCOMPLETE ANSWERS IN ANY APPLICATION DOCUMENT WILL DISQUALIFY ME FROM FURTHER CONSIDERATION FOR EMPLOYMENT. I FURTHER UNDERSTAND THAT, IF EMPLOYED, ANY MISREPRESENTATIONS OR OMISSIONS OF FACTS IN ANY APPLICATION DOCUMENT WILL BE CAUSE FOR MY IMMEDIATE DISMISSAL. I UNDERSTAND THAT, IF EMPLOYED, MY EMPLOYMENT WITH THE EMPLOYER IS NOT FOR A SPECIFIC TERM AND MAY BE TERMINATED BY ME OR THE EMPLOYER WITH OR WITHOUT NOTICE OR CAUSE AT ANY TIME, UNLESS I AM OTHERWISE COVERED BY A COLLECTIVE BARGAINING AGREEMENT. I FURTHER UNDERSTAND THAT NO ORAL PROMISE, EMPLOYER POLICY, CUSTOMER BUSINESS PRACTICE OR OTHER PROCEDURE (INCLUDING THE EMPLOYER'S PERSONNEL HANDBOOK OR ANY PERSONNEL MANUALS) CONSTITUTE AN EMPLOYMENT CONTRACT OR MODIFICATION OF THE AT WILL EMPLOYMENT RELATIONSHIP BETWEEN ME AND THE EMPLOYER, OTHER THAN A COLLECTIVE BARGAINING AGREEMENT TO WHICH I AM SUBJECT. I AUTHORIZE INVESTIGATION OF ALL MATTERS OUTLINED IN THIS APPLICATION. I HEREBY GIVE THE COMPANY AND/OR ITS DESIGNATED SUBSCRIBER PERMISSION TO CONTACT PREVIOUS EMPLOYERS, DOCTORS, MEDICAL PROVIDERS, REFERENCES, AND TO CONDUCT INVESTIGATIVE BACKGROUND INQUIRES ON ME INCLUDING CONSUMER CREDIT, CRIMINAL CONVICTIONS, MOTOR VEHICLE AND OTHER REPORTS FROM VARIOUS FEDERAL, STATE AND OTHER AGENCIES THAT MAINTAIN RECORDS RELATED TO THE ABOVE MENTIONED ITEMS, AS WELL AS, CLAIMS RECORDS ON FILE AT INSURANCE COMPANIES. I HEREBY RELEASE THE COMPANY AND ANY PERSON GIVING OR RECEIVING ANY SUCH INFORMATION FOR ANY PURPOSE RELATED TO MY EMPLOYMENT FROM ANY LIABILITY AS A RESULT OF SUCH CONTACTS. INFORMATION REGARDING CREDIT HISTORY AND DRIVING HISTORY WILL NOT BE INQUIRED INTO UNLESS IT IS NECESSARY AND DIRECTLY RELATED TO THE JOB APPLIED FOR IN THIS APPLICATION. Applicant's Signature Date
