Fillable PCFS Application Final 1 31 2018 F Application for Employment

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PCFS Application Final 1 31 2018 F Application for Employment

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File type: PDF

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PROVIDER1312018
Application for Employment
PLEASE PRINT
Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to
the application and/or interview process should notify the General Manager, District Manager or Corporate Office.
Location ________________________________________________________________________________________________________
Position(s) applied for _____________________________________________________ Date of application ______ / ______ / ______
Referral Source Advertisement Employment Relative Person ______________________
Walk-in Private Employment Agency Other _______________________
Name ___________________________________________________________________________________________________________________________________________________________
AM
If necessary, best time to call you at home is
PM
May we contact
you at work?
Yes No
AM
If yes, work number and best time to call ( )
PM
If you are under
18 and it is required, can you furnish a work permit?
Yes No
If no, please explain
Have you previously been employed by Market Broiler Restaurants or Provider Contract Food Services? Yes No
If yes provide dates
____/_____/______ - _____/_____/_____
If yes, did you pr
ovide notice of your resignation of employment from Market Broiler Restaurants or Provider Contract Food Services?
Yes No
Are you legally eligible f
or employment in this country?
Yes No
Date available for work / / What is your desired wage / salary range? $ per
Type of employment desired Full Time Part Time Temporary Seasonal
Yes No
Yes No
Yes No
Will you relocate if job requires it?
Can you perform the functions of this job (essential and/or marginal), with/without reasonable accommodation?
Will you work overtime if required?
If no, please explain
ANSWERING “YES” TO THESE QUESTIONS DOES NOT CONSTITUTE AN AUTOMATIC BAR TO EMPLOYMENT, FACTORS SUCH AS DATE OF THE OFFENSE, SERIOUSNESS AND NATURE
OF VIOLATION, REHABILITATION AND POSITION APPLIED FOR WILL BE TAKEN INTO ACCOUNT.
AN EQUAL OPPORTUNITY EMPLOYER
LAST
FIRST
MIDDLE
Address____________________________________________________________________________________________________________
Social Security # _______________________
Telephone # ( )________________________ Phone Other # ( )________________________Email________________________________________________
Employment History
Provide the following information of your past and current employers, assignments or volunteer activities, starting with the most recent (use
additional sheets if necessary). Explain any gaps in employment in comments section below.
TELEPHONE #
EMPLOYER
( )
DATES EMPLOYED
SUMMARIZE THE TYPE OF WORK
PERFORMED AND JOB RESPONSIBILITIES
FROM
TO
ADDRESS
STARTING JOB TITLE / FINAL JOB TITLE
IMMEDIATE SUPERVISOR AND TITLE
REASON FOR LEAVING
MAY WE CONTACT FOR REFERENCE? YES NO LATER
EMPLOYER
TELEPHONE #
( )
DATES EMPLOYED
SUMMARIZE THE TYPE OF WORK
PERFORMED AND JOB RESPONSIBILITIES
FROM
TO
ADDRESS
STARTING JOB TITLE / FINAL JOB TITLE
IMMEDIATE SUPERVISOR AND TITLE
REASON FOR LEAVING
MAY WE CONTACT FOR REFERENCE? YES NO LATER
EMPLOYER
TELEPHONE #
( )
DATES EMPLOYED
SUMMARIZE THE TYPE OF WORK
PERFORMED AND JOB RESPONSIBILITIES
FROM
TO
ADDRESS
STARTING JOB TITLE / FINAL JOB TITLE
IMMEDIATE SUPERVISOR AND TITLE
REASON FOR LEAVING
MAY WE CONTACT FOR REFERENCE? YES NO LATER
EMPLOYER
TELEPHONE #
( )
DATES EMPLOYED
SUMMARIZE THE TYPE OF WORK
PERFORMED AND JOB RESPONSIBILITIES
FROM
TO
ADDRESS
STARTING JOB TITLE / FINAL JOB TITLE
IMMEDIATE SUPERVISOR AND TITLE
REASON FOR LEAVING
MAY WE CONTACT FOR REFERENCE? YES NO LATER
Educational Background
A. List the last three (3) schools attended, starting with most recent. B. List number of years completed. C. Indicate degree or
diploma earned, if any. D. Grade Point Average or Class Rank. E. Major field of study. F. Minor field of study (if applicable).
A. SCHOOL
B. NUMBER OF
YEARS COMPLETED
D. GPA
CLASS RANK
E. MAJOR
F. MINOR
Skills and Qualifications
Summarize any special training skills, licenses and/or certificates that may qualify you as being able to perform job-related functions in the
position for which you are applying.
References
List name and telephone number of three business/work references who are NOT related to you and are NOT previous supervisors. If not
applicable, list three school or personal references who are not related to you.
NAME
TELEPHONE
NUMBER OF
YEARS KNOWN
( )
( )
( )
L
ist any additional information you would like us to consider,
Applicant Statement
I
certify that all information provided in order to apply for and secure work with the employer is true, complete and correct.
I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient
cause to (i) cancel further consideration of this application, or (ii) immediately discharge me from Market Broiler’s service, whenever it is
discovered.
I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all
references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify
the accuracy of all information provided by me in this application, resume, or job interview. I hereby waive any and all rights and claims I
may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information in the
employment process and all other persons, corporations or organizations for furnishing such information about me.
I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of
limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law.
I understand that this application remains current for only 30 days. At the end of that time, if I have not heard from the employer and still wish
to be considered for employment, it will be necessary to reapply and fill out a new application.
It is my understanding that PROVIDER CONTRACT FOOD SERVICE is an at-will employer and by understanding this it has been
explained to me that if I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the
employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be
required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I
understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral
or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer’s president.
I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that
federal immigration laws require me to complete an I-9 Form in this regard.
DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.
I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.
Signature of Applicant Date / / .
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For Office Use Only:
Location Schedule Updated: SHIFT(S) HIRED TO FILL: ________________________________________
Hot Schedules:
_________________________________________________________________
Employee Availability
Name___________________________ Location_________________
Date Available To Start___________ CBU Student: Y N
Desired Weekly Hours_________
Specify time frame available:
Monday Anytime NO ____________________
Tuesday Anytime NO ____________________
Wednesday Anytime NO ____________________
Thursday Anytime NO ____________________
Friday Anytime NO ____________________
Saturday Anytime NO ____________________
Sunday Anytime NO ____________________
*I understand every intention will be made to accommodate the requests outlined above, but in
some instances the staffing needs of your location will take precedence over scheduling
requests. Please indicate the reason you are unavailable.
*I am willing to work when scheduled and needed.
*If my availability changes, it is my responsibility to submit a new availability form.
Employee Signature_______________________________ Date______________
Phone Number: ___________________________________
Email Address: ___________________________________
Availability forms are to be turned into the Provider office, Yeager D123
It will take 10 days for changes to be processed.
Students must attach a copy of your class schedule.
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signature
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This Organization
Participates in E-Verify
This employer will provide the Social Security Administration
(SSA) and, if necessary, the Department of Homeland
Security (DHS), with information from each new employee’s
Form I-9 to conrm work authorization.
IMPORTANT: If the Government cannot conrm that you
are authorized to work, this employer is required to give
you written instructions and an opportunity to contact DHS
and/or the SSA before taking adverse action against you,
including terminating your employment.
Employers may not use E-Verify to pre-screen job applicants
and may not limit or inuence the choice of documents you
present for use on the Form I-9.
To determine whether Form I-9 documentation is valid, this
employer uses E-Verify’s photo matching tool to match the
photograph appearing on some permanent resident cards,
employment authorization cards, and U.S. passports with
the ofcial U.S. government photograph. E-Verify also checks
data from driver’s licenses and identication cards issued by
some states.
If you believe that your employer has violated its
responsibilities under this program or has discriminated
against you during the employment eligibility verication
process based upon your national origin or citizenship status,
please call the Ofce of Special Counsel at 800-255-7688,
800-237-2515 (TDD) or at www.justice.gov/crt/osc.
N O T I C E:
Federal law requires all employers to verify
the identity and employment eligibility of all
persons hired to work in the United States.
E-Ver
i
fy Works for Everyone
For more information on E-Verify, please contact DHS:
888-897-7781
www.dhs.gov/E-Verify
The E-Verify logo and mark are registered trademarks of Department of Homeland
Security. Commercial sale of this poster is strictly prohibited.
IF YOU HAVE THE RIGHT TO WORK,
Don’t let anyone take it away.
If you have the legal right to
For assistance in your own language:
U
Employers cannot terminate you
work in the United States, there are
Phone: 1-800-255-7688 or
C
because of E-Verify without giving
laws to protect you against
(202) 616-5594
you an opportunity to resolve the
discrimination in the workplace.
For the hearing impaired:
problem.
TTY 1-800-237-2515 or
I
You should know that –
(202) 616-5525
E
In most cases, employers cannot
require you to be a U.S. citizen or
E-mail: osccrt@usdoj.gov
In most cases, employers cannot
a lawful permanent resident.
deny you a job or fire you because
Or write to:
of your national origin or
If any of these things have
U.S. Department of Justice – CRT
citizenship status or refuse to
happened to you, contact the
Office of Special Counsel – NYA
accept your legally acceptable
Office of Special Counsel (OSC).
950 Pennsylvania Ave., NW
documents.
Washington, DC 20530
Employers cannot reject documents
because they have a future
expiration date.
.S. Department of Justice
ivil Rights Division
Office of Special Counsel for
mmigration-Related Unfair
mployment Practices
www.justice.gov/crt/about/osc
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PCFS Application Final 1 31 2018 F Application for Employment

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Completed 1 November 2019

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