Fillable Printable Hill & Markes Employment Application Form

Hill & Markes Employment Application Form

Hill & Markes, Inc. is a Tobacco-Free Workplace & an Equal Opportunity Employer

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P.O. Box 7 • Amsterdam, NY 12010

518-842-2410 • 800-836-7877 • Fax: 888-842-1207

EMPLOYMENT APPLICATION

Hill & Markes, Inc. supports equal opportunity for all employment candidates, as well as

existing associates, without regard for race, sex, age, creed, color, religious preference,

veteran status, military status, sexual orientation, genetic predisposition or carrier status,

national origin, status as a victim of domestic violence, disability or marital status in its

employment practices.

PLEASE PRINT

Date:

Position applied for:

Referral source:

Newspaper Ad Employment Agency Internet

Other:

(

please explain – if H&M employee, state employee’s name)

Name:

Last First Middle

Address:

Street City State Zip

Home #: Cell #: E-mail:

Are you over the age of 18? YES

If No, employment is subject to verification that you are of minimum legal age.

Are you employed now? YES

If yes, may we contact your present employer? YES

Are you prevented from lawfully becoming employed in this country because of Visa or

Immigration Status? YES

NOTE: Proof of citizenship or immigration status will be required upon employment.

WORK AVAILABILITY

On what date will you be available to work?

Are you available to work: Full-time Part-time Shift Work Temporary

What hours (not how many) are you available to work?:

Are you available to work overtime? YES

Are you on a layoff and subject to recall? YES

Hill & Markes, Inc. is a Tobacco-Free Workplace & an Equal Opportunity Employer

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Have you been convicted of a felony within the last 7 years? YES NO

(Conviction will not nece ssarily disqualify applicant from employment.)

If you answered yes, please explain:

Summarize special skills and qualifications acquired from employment or other experiences that

could be relevant to your ability to perform the job applied for:

Provide the names, addresses, and telephone numbers for three references. Do not list

relatives or previous employers:

APPLICANT NOTICE AND ACKNOWLEDGMENT

If you require an accommodation because of a physical or mental disability in order to

participate in any phase of the application process, please make that fact known to the

individual processi ng your application.

If you are required to take any pre-employment screening tests, and you require an

accommodation because of a physical or mental disability to enable you to take or successfully

complete such a test, please make that fact known in advance to the test administrator.

If an offer of employment is made and, because of a physical or mental disability, you will need

an accommodation to perform any essential job function, please make that fact known to the

individual processi ng your application.

If an offer of employment is made, I agree to submit to a medical examination, including a drug

test, and understand that my subsequent employment will be contingent on the results of the

medical examination and drug test.

I understand that the examining physician may ask questions regarding my current health

condition, health history, health insurance claim and workers’ compensation claim history and

that all such information will be retained in confidential medical files, to be released only in

accordance with federal and state law.

I also understand that falsification of any such information that I furnish could result in

termination of my employment, if hired.

Signature Date

Hill & Markes, Inc. is a Tobacco-Free Workplace & an Equal Opportunity Employer

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EMPLOYMENT EXPERIENCE

Start with your present or last job. Include any military service assignments and volunteer

activities. You may exclude names of organizations that indicate race, color, religion, sex, or

national origin.

EMPLOYER (most recent):

ADDRESS

TELEPHONE:

SUPERVISOR:

DATES EMPLOYED:

FROM:

TO:

HOURLY PA Y/SALARY:

START:

FINAL:

REASON FOR LEAVING:

JOB TITLE:

DUTIES PERFORMED:

EMPLOYER:

ADDRESS

TELEPHONE:

SUPERVISOR:

DATES EMPLOYED:

FROM:

TO:

HOURLY PA Y/SALARY:

START:

FINAL:

REASON FOR LEAVING:

JOB TITLE:

DUTIES PERFORMED:

EMPLOYER:

ADDRESS

TELEPHONE:

SUPERVISOR:

DATES EMPLOYED:

FROM:

TO:

HOURLY PA Y/SALARY:

START:

FINAL:

REASON FOR LEAVING:

JOB TITLE:

DUTIES PERFORMED:

Do you currently receive pay from any other source? YES

(Do not disclose alim ony or child support payments.)

If you answered yes, please explain:

Hill & Markes, Inc. is a Tobacco-Free Workplace & an Equal Opportunity Employer

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EDUCATION/TRAINING

Circle last grade completed or code for last degree receiv ed: 1 2 3 4 5 6 7 8 9 10 11 12 (High School)

13 14 (Technic al/Vocational School); 15 (College Freshman); 16 (College Sophomore)

17 (College Junior); 18 (Bachelor’s Degree); 19 (Master’s Degre e); 20 (Ph.D.)

Are you currently attending school? Yes No If yes, estimated graduation date?

COLLEGE INFORMATION HIGH SCHOOL INFORMATION

Undergraduate College/

University Attended:

Name of School

Attended:

Undergraduate

Major:

Location:

Major Courses Taken:

Type of Degree

Received:

Diploma Received: Yes No

Graduate College/

University Attended:

APPRENTICE, BUSINESS, TECHNICAL OR

VOCATIONAL SCHO OL

Graduate

Major Field:

Name of School

Attended:

Type of Degree

Received:

Location:

Major Field of Study:

Honors Received:Diploma/Certificate Rece ived:Yes No

List Any Specialized Training, Apprenticeship, Skills, and Extracurricular Activities:

JOB APPLICANT’S AGREEMENT AND CERTIFICATION

I certify that the information given by me in this application is true in all respects, and I agree that if the

information given is foun d to be false in any way, it shall be consid ered sufficient caus e for denial of employment

or discharge. I authorize the use of any information in this application to verify my statements and I authorize

past employers, all references, and any other persons to answer all questions asked concerning my ability,

character, reputation, an d previous employment record. I release al l such persons from any liabilit y or damages

on account of having furnis hed such information.

I understand that nothing contained in this employment application or in the granting of an interview is

intended to create an employment contract between Hill & Markes, Inc. and myself for either employment or for

the providin g of any such promise or guar antee is binding upon Hill & M arkes, Inc. unless made in writing. If an

employment relationship is established, I understand that I have the right to terminate my employment at any

time and that Hill & Markes Inc. retains the sa me right.

I understand my becoming employed and/or my continued employment are subject to the results of any

physical e xamination related to my job duties in accordance with company policies a nd procedures.

I understand that if employed, policies an d rules that are issued are not conditio ns of emplo yment and that

the employer may revise poli cies and procedures, in whole or in part, at any time.

I understand that this application is for the specific job applied for and I would have to reapply for any

future opportunities that could become availa ble.

Signature of Applicant Date

TO BE COMPLETED BY HILL & MARKES PERSONNEL

Position applied for: Department:

Was position applied for available on date application filed? Yes No

Was this appl icant hired? Yes No Hourly Rate/Salary:

Date of Employment: Department:

Job Title: Full-time Part-time

By: Title: Date:

Montgomery County

Employee Questionnaire-RLF

FORM # 2

The employer you are completing an application for has received financing assistance from the

Montgomery County Revolving Loan Fund. A condition of the receipt of this assistance is that all

prospective employees of the firm must provide certain information regarding their family income

level as of the day the application is completed. This information is forwarded to Montgomery

County and is maintained and kept entirely CONFIDENTIAL.

Please provide the information requested as follows.

Applicant Name: __________________________________

Position Applied for : _______________________________

Application Date:_____________

Please circle the appropriate number of persons in your family ( family is defined as all persons living

in the same household who are related by birth, marriage, or adoption). Then check the income

range which most closely matches the total annualized income of your family as of today's date.

BelowBetweenBetweenAbove

Very LowLowModerate

1 Person$12,150$20,20032,350$

2 Persons13,850$ 23,100$ 36,950$

3 Persons15,600$ 26,000$ 41,550$

4 Persons17,300$ 28,850$ 46,150$

5 Persons18,700$ 31,200$ 49,850$

6 Persons20,100$ 33,500$ 53,550$

7 Persons21,500$ 35,800$ 57,250$

8 Persons22,850$ 38,100$ 60,950$

In order to assure that non-discrimination requirements of the federal program are met, we ask

that you complete the following:

"I consider myself to be" one of the following: (Check one only)

WhiteAsianBlack

_____HispanicNative American

Is your head of household female headed?YN

Signed:_____________________________________Date:___________________

Employer Verification:

The above person was hired on:_______________________Full Time ______Part Time

Employer Signature:___________________________Title:__________________ Date:___________

updated 2013