APPLICATION FOR EMPLOYMENT An Equal Opportunity/Affirmative Action Employer PERSONAL INFORMATION Date_____________________________________________ Name_____________________________________________________________________________________ Last First Middle Present Address____________________________________________________________________________ Street City State Zip Permanent Address_________________________________________________________________________ Street City State Zip Telephone Number (________) ___________________ Are you 18 years of age or older?  Yes  No How did you find out about General Produce/ this job opening?____________________________________ Do you have any friends or relatives working for General Produce?  Yes  No If yes, who?: __________________________________________________________________________________________ EMPLOYMENT DESIRED Position :_______________________________Date Available:__________Desired Wage:________________  Full Time  Part Time Specify Hours/Days:___________________________ If applying for a Warehouse/Operations position, which shifts are you available to work?  Day  Swing/ Night Are you able to perform the primary functions of the job?  Yes  No. If no, please describe what functions cannot be performed (note: General Produce Co. will consider reasonable accommodations that may be necessary for eligible employees): __________________________________________________________________________________________ __________________________________________________________________________________________ Dates of any previous employment with General Produce Company From ______to______ Supervisor_____________________________________________________________ For Office Use Only ABRA_________________ TEST NOTICE_________________ MEMO_____________________ 1 EDUCATION AND TRAINING School Name, City, State # Years Graduate? Degree/Diploma  Si  No High School ______________________________________________________________________________________ Vocational/  Si Trade/  No Business ______________________________________________________________________________________  Si  No College/ University ______________________________________________________________________________________ FORMER EMPLOYERS Describe all previous employment. (List most recent employer first) Use additional paper if necessary. Dates of employment Name and phone e number of company Rate of Pay Position Held Reason(s) for Leaving __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Relevant Experience or Special Skills: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ REFERENCES Name Phone# Relationship __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ NOTICE New employees are required to produce verification of their legal right to work in the United States. If you are offered employment, can you produce sufficient documentation of your identity and right to work in the United States, and attest under penalty of perjury that the documents you produce are genuine and relate to you?  Yes  No ADDITIONAL INFORMATION Have you ever been convicted of a felony or of any crime for which you served a jail or prison sentence? ______________ (Do not include convictions under Health and Safety Code Sections 11357(b) or (c), 11360(b), 11364, 11365, or 11550 related to marijuana, which occurred two or more years ago, or referrals to any pre-trial or post-trial diversion program) Are you currently awaiting trial for any criminal offense? _______ Have you ever initiated an act of violence in the workplace? ________ A “yes” answer to these questions will not necessarily disqualify you. Please explain any “yes” answer so that individual circumstances can be considered. Use additional paper if necessary: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Prospective employees may be required to undergo the General Produce Company’s drug/alcohol examination. The examination includes laboratory testing for a urine sample from a prospective employee to determine the presence of certain drugs and/or alcohol in the body. Please Note: You should not rely upon a contingent offer of employment from General Produce Company or otherwise engage in any activity based upon a contingent offer of employment. Unless or until a final offer of employment is made, you should not take any action which could result in financial loss if a contingent offer is withdrawn, such as giving notice of intent to terminate current employment, selling real estate, or incurring any other costs associated with accepting employment with General Produce Company. No such activity should be undertaken until after medical clearance has been received and you have received a final offer of employment from General Produce Company. Under no circumstances should you report to work before medical clearance is received. AGREEMENTS I authorize the investigation of all statements contained in this application. I understand that falsification, misrepresentation or omission of facts will result in immediate dismissal or removal of my application from consideration. I authorize General Produce Company to secure information about my background and experience from other employers, education institutions, references and government agencies, and for those parties to provide information concerning my background and experience. I release all parties from any liability arising there from. __________ Initial 4 If General Produce Company employs me, I agree to conform to the rules and regulations of General Produce Company. I also understand and agree that, except for employment at-will status, my wages, hours, working conditions, job assignments and compensation are subject to change by General Produce Company. I understand my employment can be terminated, with or without cause and with or without notice, at any time at the option of General Produce Company or myself. I understand that, other than the President of General Produce Company, no manager, supervisor or representative of General Produce Company, has authority to enter into any agreement for employment for any special period of time, or to make any agreement contrary to at-will employment. Only the President of General Produce Company has the authority to change my at-will status, and then only in a writing expressly changing my at-will status. ___________ Initial My signature below certifies that I have read and understand this application, and to the best of my knowledge, the information I provided is true and correct. My signature below also certifies that I agree to be bound by the terms and conditions of employment stated in this application. This application contains all the understandings and agreements between me and General Produce Company concerning the nature of my employment, if any, by General Produce Company, and supersedes all prior and/or contemporaneous practices, oral or written agreements, understandings, representations and promises, express or implied, between me and General Produce Company. ____________________________________________________ Applicant Signature ___________________ Date It is General Produce Company’s policy to fill every position without regard to race, color, religion, creed, sex, marital status, age, national origin, ancestry, disability, medical condition, sexual orientation or any other consideration made unlawful by applicable federal, state, or local laws. General Produce Company is an equal opportunity employer and selects employees on the basis of qualifications. Please contact the President of General Produce Company if you have any questions or complaints regarding this policy VOLUNTARY SELF IDENTIFICATION QUESTIONNAIRE An Affirmative Action Employer General Produce Company is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, the employer invites all applicants to voluntarily self-identify their race, ethnicity and gender. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information will be kept confidential and will only be used in accordance with the provisions of applicable laws, executive orders and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual. Name__________________________________________________ Date___________________________________________________ □Male □Female Please check the race/ethnicity in which you would like to be identified: □Asian □Black or African American □Hispanic or Latino □American Indian or Alaska Native □White □Two or More Races □Native Hawaiian or Other Pacific Islander I Decline to self-identify Voluntary Self-Identification of Disability Form CC-305 OMB Control Number 1250-0005 Expires 1/31/2017 Page 1 of 1 Why are you being asked to complete this form? Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities.i To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way. If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier. How do I know if I have a disability? You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition. Disabilities include, but are not limited to: • • • • • Blindness Deafness Cancer Diabetes Epilepsy • • • • • Autism Cerebral palsy HIV/AIDS Schizophrenia Muscular dystrophy • • • • Bipolar disorder Major depression Multiple sclerosis (MS) Missing limbs or partially missing limbs • • • • Post-traumatic stress disorder (PTSD) Obsessive compulsive disorder Impairments requiring the use of a wheelchair Intellectual disability (previously called mental retardation) Please check one of the boxes below: ☐ YES, I HAVE A DISABILITY (or previously had a disability) ☐ NO, I DON’T HAVE A DISABILITY ☐ I DON’T WISH TO ANSWER __________________________ Your Name __________________________ Your Signature __________________ Today’s Date Voluntary Self-Identification of Disability Form CC-305 OMB Control Number 1250-0005 Expires 1/31/2017 Page 2 of 10 Reasonable Accommodation Notice Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment. 1 Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp. PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete. Submit Application