Work with Midcon Job Application Employment Application Form Midcon is an Equal Opportunity Employer. We encourage all qualified individuals to apply for employment. If you require accommodation to complete the application, testing or interview process, please contact the Human Resources Department. * Name First Last Address Street Address Address Line 2 City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State ZIP Code * Phone * Email Employment Desired Select Job Type - Full Time Part Time Temporary Select Desired Shift - 5x8 Hour Days 4x10 Hour Days 9/80's Date Available First Job Choice Referred By Referral Source - TV Facebook Online Ad Radio Friends or Family Billboard Snapchat Email Other Pay Requirement Education Attach additional pages as necessary HIGH SCHOOL High School Name Diploma or Degree Major, Subject, Award, etc. TRADE OR BUSINESS SCHOOL Trade or Business School Years Attended Diploma or Degree Major, Subject, Award, etc. COLLEGE College/University Name Years Attended Diploma or Degree Major, Subject, Award, etc. Military Service Branch of Service From To Rank Service-Related Training or Duties References: List three people not related to you whom you have known at least one year. Reference 1: Name Address Phone Relationship Reference 2: Name Address Phone Relationship Reference 3: Name Address Phone Relationship Work Experience (Please list all work experience for the last ten years and your last three employers. Begin with your most recent employer attach additional as necessary) Most Recent Employer Job Title and Duties Address Street Address Address Line 2 City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State ZIP Code From To Starting Salary Ending Salary Supervisor First Last Phone Reason for leaving Second Most Recent Employer Job Title and Duties Address Street Address Address Line 2 City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State ZIP Code From To Starting Salary Ending Salary Supervisor First Last Phone Reason for leaving Third Most Recent Employer Job Title and Duties Address Street Address Address Line 2 City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State ZIP Code From To Starting Salary Ending Salary Supervisor First Last Phone Reason for leaving Special Qualifications History Have you previously applied for employment at this company? No Yes If yes please explain Do you have any relatives employed by this company or by any competitors? No Yes Please provide name(s), title(s) and company name(s). Have you been charged or convicted of any misdemeanor or felony violating any law other than minor traffic offenses in the past ten years? No Yes Please provide the reason for the conviction, the date, the city and state. A conviction record will not necessarily bar you from employment. Please read and initial the following statements Accurate Information I certify that the information here and in my resume is true and complete. I understand that any incomplete, misleading or false information will disqualify my application or be cause for dismissal. I authorize the company to contact all references listed here and further investigate my work experience and qualification. * Initials Conditions I understand that any offer of employment is contingent on the company's satisfaction with my: 1) drug test results; 2) identification and work authorization documents; 2) references and 4) background check. * Initials Employment At Will I understand and agree that if I am hired my employment will be for no defined period and that it may be terminated by me or by the company at any time, with or without cause or notice. I also understand that the company may change my job responsibilities or change my position at its discretion. I further understand that these terms of employment cannot be changed, except in writing, signed by the company president. * Initials * Today's Date Midcon Cables Applicant Information Affirmative Action Midcon Cables is a federal contractor (or subcontractor). As such, we are required to maintain demographic information about our applicants. We would appreciate your help in completing this form to ensure the accuracy of our information. This form is completely voluntary. It will be kept confidential, except as required to administer our Affirmative Action Plan. Name First Last Date Job Objective Referral Source Gender Male Female Race Please mark one or more of the following categories that best describes your ethnic background. (The definitions are government terms.) Black - All persons having origins in any of the Black racial groups of Africa Hispanic -All Persons of Mexican, Puerto Rican, Cuban or South American or other Spanish culture, regardless of race. Asian - All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent or the Pacific Islands. This area includes, for example, China, Japan, Korea, the Philippine Islands and Samoa. Native American - All persons having origins in any of the original peoples of North America and who maintain cultural identification through tribal affiliation or community recognition. Meets Bureau of Indian Affairs definition standards. White - Not covered above. Disability How do you know if you have a disability? Click Here * Voluntary Self-Identification of Disability Yes, I Have A Disability, Or Have A History/Record Of Having A Disability No, I Don’t Have A Disability, Or A History/Record Of Having A Disability I Don’t Wish To Answer Please explain Veteran What are the Veteran Classifications? Click Here * Voluntary Veteran Self-Identification Disabled Veteran Recently separated Veteran Active duty wartime or campaign badge Veteran Armed Forces service medal Veteran I am not a protected Veteran I decline to disclose my protected Veteran status
