Employment Application Form

APPLICATION FOR EMPLOYMENT ROARING SPRING WATER A DIVISION OF ROARING SPRING BLANK BOOK COMPANY
The Roaring Spring Blank Book Company is an Equal Opportunity employer. In compliance with Federal and State equal opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, sexual orientation, disability, or any other protected group status.

Personal Information

Date*

Name*

First Middle Last

Present Address*

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

Home Phone*

Work Phone

Cell Phone

Email Address*

Social Security Number*

Are you 18 years or older?*

Yes
No

Are you eligible to work in the United States?*

Yes
No

(Proof of eligibility will be required upon offer of employment)

Have you ever been convicted, pled guilty, “no contest”, or admitted guilt to any misdemeanor or felony crime?*

Yes
No

If yes, explain circumstances and date (a record of conviction will not necessarily disqualify you from employment.)

Have you previously worked for any division of Roaring Spring Blank Book listed below?*

Yes
No

If yes, please state which division and dates of employment:

How did you learn of this opening?*

Have you ever been a member of the armed forces of the United States?*

Yes
No

If yes, list any skills developed in the military which relate directly to the job being applied for:

Have you used tobacco within the last 6 months?

Yes
No

Applicants for Pennsylvania based jobs should answer this question. (Applicants for West Virginia based jobs should not answer the question.)

Position being applied for:*

Type of position you are seeking:*

Full-time
Part-time
Temporary
Summer/Student

Are you currently employed?*

Yes
No

May we contact your present employer?

Yes
No

Date you can start:*

Wage desired:*

EDUCATION

High School

Name and Location

Course of Study and # Years Completed

Degree/Diploma

College or University

Name and Location

Course of Study and # Years Completed

Degree/Diploma

Specialized Training, Trade School, etc.

Name and Location

Course of Study and # Years Completed

Degree/Diploma

Other Education

Name and Location

Course of Study and # Years Completed

Degree/Diploma

EMPLOYMENT HISTORY

List below all present and past employers over the last seven years, starting with your most recent employer.

Employer #1

Employer

Address

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

Start Date

Termination Date

Phone Number

Starting Wage Rate

Ending Wage Rate

Supervisor's Name

Job Position

Major Duties

Reason for leaving

Employer #2

Employer

Address

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

Start Date

Termination Date

Phone Number

Starting Wage Rate

Ending Wage Rate

Supervisor's Name

Job Position

Major Duties

Reason for leaving

Employer #3

Employer

Address

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

Start Date

Termination Date

Phone Number

Starting Wage Rate

Ending Wage Rate

Supervisor's Name

Job Position

Major Duties

Reason for leaving

Employer #4

Employer

Address

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

Start Date

Termination Date

Phone Number

Starting Wage Rate

Ending Wage Rate

Supervisor's Name

Job Position

Major Duties

Reason for leaving

PERSONAL REFERENCES (do not list relatives)

Reference #1

Name*

First Last

Address*

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

Phone*

Relationship & years acquainted*

Reference #2

Name*

First Last

Address*

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

Phone*

Relationship & years acquainted*

Reference #3

Name*

First Last

Address*

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

Phone*

Relationship & years acquainted*

APPLICANT CERTIFICATION – Please read carefully and sign below

Disclosure to Applicants Concerning Drug/Alcohol Testing
If you are offered a position with any of the divisions of the Roaring Spring Blank Book Company, (the Company), you will be given a drug/alcohol test as a condition of employment.
Your refusal to timely submit to a drug/alcohol test or your failure to pass such a test means you will not be employed by the Company.

Complete and Accurate Information
I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I have personally completed this application.
I understand that any omission or misstatement of material fact on this application, or any document used to secure employment, shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

At-Will Employment
I understand and agree that if I am employed, my employment will be “at-will” which means that the Company may terminate the employment relationship at any time, with or without cause and with or without notice. This provision may not apply if an employee is covered under a collection bargaining agreement. Likewise, the Company will respect my right to terminate my employment at any time, with or without cause or with or without notice.

Testing Authorization
If offered a position with the Company, I hereby agree to any legally permitted physical, psychological, skill, drug, or medical test required by the Company as a condition of employment. I understand that any offer of employment is contingent upon my participation and successful completion of any required physical or other examination as identified within this application.

Investigation Authorization
I authorize investigation into all statement and references contained in this application.
This may include credit, driving, criminal background, references and other background checks. By applying for this job, I also authorize post-hire investigation into my credit, driving and criminal background.

Company Obligation
I understand and agree that the Company’s acceptance of this job application does not mean that a position for which I am qualified is open (unless specifically posted) or that the Company has agreed to hire me.
I understand that the Company is under no obligation to hire me as a result of accepting this completed application.

Application Agreement*

I HAVE READ AND UNDERSTAND AND AGREE TO THE ABOVE STATEMENTS. I UNDERSTAND THAT MY APPLICATION WILL NOT BE ACCEPTED UNLESS IT IS COMPLETED IN ITS ENTIRETY, INCLUDING THE VOLUNTARY SELF IDENTIFICATION SURVEY AND MY SIGNATURE APPEARS BELOW.

Name*

First Last

VOLUNTARY SELF-IDENTIFICATION SURVEY FOR ROARING SPRING BLANK BOOK COMPANY

It is the policy of Roaring Spring Blank Book Company to provide equal employment opportunity to all employees and applicants for employment without regard to race, color, sex, national origin, religion, sexual orientation, age, disability or veteran status. Likewise, the Company maintains written Affirmative Action Plans for women, minorities, disabled persons and protected veterans.

This Organization is subject to certain non-discrimination and affirmative action record-keeping and recording requirements which require us to invite job applicants and employees to voluntarily self-identify their race/ethnicity and gender. The information obtained will be kept confidential and may only be used in accordance with the provisions of applicable federal laws, executive orders, and regulation, including those which require the information to be summarized and reported to the federal government for civil rights enforcement purposes.

Completion of this sheet is voluntary and is not a requirement for employment.
If you choose not to self-identify at this time, please be advised that the Federal Government requires this Employer to determine the information asked below by a visual survey and/or other available information, where possible.

Name

First Last

Date

Position Applied For:

Division:

Gender:

Male
Femaile

Race:

American Indian or Alaska Native (not Hispanic or Latino) - A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.
Asian – (Not Hispanic or Latino) –A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippines, Thailand, and Vietnam.
Black or African American (Not Hispanic or Latino) – A person having origins in any of the black racial groups of Africa.
Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
Native Hawaiian or Other Pacific Islander (Not Hispanic of Latino) –A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
White (Not Hispanic or Latino) – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Two or More Races (Not Hispanic or Latino) – All persons who identify with more than one of the above five races.
Do Not Want to Disclose

Personal Information

EDUCATION

EMPLOYMENT HISTORY

PERSONAL REFERENCES (do not list relatives)

APPLICANT CERTIFICATION – Please read carefully and sign below

VOLUNTARY SELF-IDENTIFICATION SURVEY FOR ROARING SPRING BLANK BOOK COMPANY

Route Sales Driver

Route Sales Driver