M&R Application for Employment

Non-Discrimination Policy

Minton & Roberson, Inc. provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, gender, sexual orientation, national origin, age, disability, marital status, amnesty, or status as a covered veteran in accordance with applicable federal, state, and local laws, Minton & Roberson, Inc. complies with applicable state and local laws governing non-discrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment including, but not limited to, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

General Information

Position(s) Applied For*

Referral Source*

Newspaper
Friend
Employment Agency
College/University
Professional Journal
Internet Search
Relative
Walk-In
Other

Other referral source*

Name*

First Middle Last

Address*

Street Address Address Line 2 City State ZIP Code

Cell Phone Number*

Home Phone Number

Email*

Enter Email Confirm Email

Have you ever filed an application here before?*

Yes
No

If yes, give date*

Have you ever been employed here before?*

Yes
No

If yes, give date*

Are you currently employed?*

Yes
No

If yes, may we contact your employer?*

Yes
No

Are you a United States citizen?*

Yes
No

If no, do you have a valid work permit?*

Yes
No

Employment desired:*

Full-Time
Part-Time
Temporary

When are you available to work?*

Are you on a lay-off and subject to recall?*

Yes
No

In the past five years, have you been convicted of an offence other than a minor traffic violation?*

Yes
No

If yes, please explain:*

Have you ever been convicted of a felony?*

Yes
No

If yes, please explain:*

Do you have any physical or mental condition that prevents you from performing the duties and responsibilities of this position?*

Yes
No

If yes, please explain:*

Education

Please check all types of schools you have attended:*

High School
College
Graduate School
Business or Trade School
Professional School

High School

High School Attended*

High School Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Number of High School Years Completed*

High School Major / Degree*

College

College Attended*

College Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Number of College Years Completed*

College Major / Degree*

Graduate School

Graduate School Attended*

Graduate School Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Number of Graduate Years Completed*

Graduate Major / Degree*

Business or Trade School

Business or Trade School Attended*

Business or Trade School Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Number of Business or Trade School Years Completed*

Business or Trade School Major / Degree*

Professional School

Professional School Attended*

Professional School Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Number of Professional School Years Completed*

Professional School Major / Degree*

Special Honors

List any special honors you received at any of the schools completed above.

Educational Special Honors

Computer Skills

Check off those computer skills with which you are proficient (any version):*

If other, please provide additional skill(s)*

Driver's License

Do you have a driver's license?*

Yes
No

Expiration date:*

Driver's License Number*

Driver's License State of Issue*

Driver's License Type*

Operator (Standard)
Commercial (CDL)
Chauffeur

Have you had any accidents in the past three years?*

Yes
No

If yes, how many?*

Have you had any moving violations during the past three years?*

Yes
No

If yes, how many?*

Military

Are you a veteran of the United States military service?*

Yes
No

If yes, what branch?*

If yes, date entered:*

Date discharged:*

Please describe any special skills or training acquired while in the service:*

Other Special Skills

Please list other special skills you may have, e.g., fluency in other languages, licenses, certifications, special training required for the position for which you are applying, etc.

Work Experience

Please list your work experience beginning with your most recent job. If you were self-employed, give firm name. Space for additional information, if necessary, can be entered at the end of this section. Exclude organization names which indicate race, color, creed, national origin, age, religion, sexual orientation, gender identity, gender expression, veteran status, or disability.

Most Recent Employment

Organization / Employer Name*

Employer Phone*

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date Employment Started:*

Date Employment Ended:*

Supervisor's Name

Reason for Leaving:*

Work Performed:*

Additional Employment*

How many organizations/employers would you like to provide?

Employment #2

Organization / Employer Name*

Employer Phone*

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date Employment Started:*

Date Employment Ended:*

Supervisor's Name

Reason for Leaving:*

Work Performed:*

Employment #3

Organization / Employer Name*

Employer Phone*

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date Employment Started:*

Date Employment Ended:*

Supervisor's Name

Reason for Leaving:*

Employment #4

Organization / Employer Name*

Employer Phone*

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date Employment Started:*

Date Employment Ended:*

Supervisor's Name

Reason for Leaving:*

Work Performed:*

Additional Employment Information

Please include any additional employment information if necessary.

References

Please list two references other than relatives or previous employers.

Reference #1

Reference's Name*

First Last

Reference's Organization/Company*

Reference's Position*

Reference's Phone Number*

Reference's Company Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Reference #2

Reference's Name*

First Last

Reference's Organization/Company*

Reference's Position*

Reference's Phone Number*

Reference's Company Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Waivers and Disclosures

At-Will Employment

It is my understanding that this employment application, or the granting of an oral interview, does not represent a contract of employment or a promise of future benefits by this organization. I understand and agree that, if hired, my employment will be at-will in nature and may be terminated, with or without cause, at any time, by either myself or my employer. I also understand that this written statement supersedes any and all oral representatives made by agents or representatives of this organization.

Certification of Truth and Accuracy

I certify that the information in this application is true, complete and correct. I understand that false answers, statements, or significant omissions made by me on this form shall be sufficient cause for denial of employment or discharge.

Agreement

On entering the employ of Minton & Roberson, I agree to observe all the rules of my employer and governmental regulations which may apply to my duties. I understand that any continuation of my employment shall depend upon satisfactory replies on any background check and from my references, acceptance by the bonding company and performance satisfactory at all times to my employer. I understand and agree that my employment is for no definite period of time and may, regardless of the date of payment of my wages and salary, be terminated, with or without cause or notice, and without liability for doing so at any time. I understand that no representative of Minton & Roberson, other than the President of the Company, has authority to enter into any agreement for employment for any specified period of time or make any agreement contrary to the foregoing, and that any such agreement, to be enforceable, must be in writing and signed by the President of the Company.

I hereby acknowledge that Minton & Roberson or its agents may wish to conduct a complete investigation of my background and suitability to provide services to Minton & Roberson. I hereby consent to and authorize the release to Minton & Roberson or its agent of any and all information in the possession of any police department or other law enforcement agency, department of motor vehicles, any other state or federal agency, any personnel representing any school which I have attended, any past or present employer, any bank or other financial institution, or any credit bureau or other credit reporting agency.

My signature appearing hereon should be accepted by any of the above described person or entities as my request to disclose information in their possession to Minton & Roberson or its agents. I hereby release from any and all liability Minton & Roberson and its agents including any persons or entities described above which either gathers or releases information pursuant to this consent and authorization.

I further consent to any testing as may be required by Minton & Roberson, including but not limited to drug and/or alcohol testing.

Digital Signature*

First Last

By providing a digital signature of your first and last name, you are consenting and agreeing to the waivers, disclosures, and agreements stated.

This application will be considered active for a maximum of ninety (90) calendar days. If you wish to be considered for employment after that time, you must re-apply. For inquiries regarding the Company's nondiscrimination policies, contact Human Resources, Minton & Roberson, 1100 International Plaza, Chesapeake, Virginia 23323.

Applicant Data Record

Non-Discrimination Policy: Minton & Roberson, Inc. is an equal opportunity employer and does not discriminate on the basis of race, color, religion, age, sex, national origin, marital status, gender identity, gender expression, veteran's status or non-disqualifying disability.

Affirmative Action Survey

Government agencies require periodic reports on the sex, ethnicity, disability, and veteran status of applicants. Submission of information about a disability is voluntary. This data is for analysis and affirmative action only.

Select one*

Male
Female

Select one*

White
Black
Hispanic
American Indian/Alaskan Native
Asian/Pacific Islander

Check any that apply.

Disabled
Vietnam Era Veteran
Disabled Veteran

Special Employment Notice

Disabled veterans, Vietnam Era veterans, and individuals with a physical or mental disability:

Government contractors are subject to Section 402 of the Vietnam Era Veterans Readjustment Act of 1974 which requires that they take affirmative action to employ and advance in employment qualified disabled veterans and veterans of the Vietnam Era, and Section 503 of the Rehabilitation Act of 1973, as amended, which requires government contractors to take affirmative action to employ and advance in employment qualified disabled individuals.

If you are a disabled veteran, or have a physical or mental disability, you are invited to volunteer this information. The purpose is to provide information regarding proper placement and appropriate accommodation to enable you to perform the job in a proper and safe manner. This information will be treated as confidential. Failure to provide this information will not jeopardize or adversely affect any consideration you may receive for employment.

Please check all boxes that apply to you:*

Disabled Individual
I do not want to identify my veteran status
I am not a veteran
I am a veteran but not covered by the definitions on this form
Disabled Veteran (see definition below)
Recently Separated Veteran (see definition below)
Armed Forces Service Medal Veteran (see definition below)
Other Protected Veteran (see definition below)

Disabled Veteran: Either (1) a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administrated by the Secretary of Veterans Affairs, or (2) a person who was discharged or released from active duty because of a service-connected disability.

Recently Separated Veteran: Any veteran during the three year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval or air service.

Armed Forces Service Medal Veteran: Any veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces Service Medal was awarded pursuant to Executive Order 12985. For the current list of military operations for which an Armed Forces Service Medal was awarded, please visit http://www.opm.gov/staffingportal/vgmedal2.asp

Other Protected Veteran: A veteran who served on active duty in the U.S. military, ground, naval, or air service during a war or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense. (For the current list of campaigns and expeditions for which a campaign badge was authorized, visit http://www.opm.gov/staffingportal/vgmedal2.asp)

Date Discharged*

Digital Signature*

First Last

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