Employment Application Form

Name

First

Middle

Last

Phone

Email

Address

Address Line 1

Address Line 2

City

State

Zip Code

Are you eligible for employment in the United States.

Yes
No

Are you currently using an ID/DD Waiver?

Yes
No

Are You a Veteran?

Yes
No

Have You Ever Been Employed by PORTCO?

Yes
No

Select All You've Attended

High School
College
Graduate School
Trade School/Other

List Any Relevant Skills You Possess

List Any Relevant Certifications Or Qualifications

Are you currently employed?

Yes
No

Previous Employer 1

Name of Current Employer

Position Held

Start Date

End Date

Reason for Leaving?

Previous Employer 2

Name of Current Employer

Position Held

Start Date

End Date

Reason for Leaving?

References

List three persons, not related to you, who have known you for at least one year.

Reference #1

Name of Reference #1

Relationship

Phone

Email

Address

Address Line 1

City

State

Zip Code

Reference #2

Name of Reference #2

Relationship

Phone

Email

Address

Address Line 1

City

State

Zip Code

Reference #3

Name of Reference #3

Relationship

Phone

Email

Address

Address Line 1

City

State

Zip Code

Address Current How

Equal Opportunity Employer

The information contained in this application is true and correct to the best of my knowledge and is subject to inquiry by PORTCO, Inc. I understand that incorrect or misleading statements on this application would be cause for dismissal, if employed.

PORTCO, Inc. is an Equal Opportunity Employer. As required by law, we must record certain information to be made a part of our Affirmative Action Program.

Applications for employment are also invited to participate in the Affirmative Action Program by reporting their status as handicapped, disabled veteran, veteran of the Vietnam era or other minority. In extending this invitation you are also advised that: (a) applicants are under no obligation to respond, but may do so in the future if they choose; (b) responses will remain confidential within the Human Resources Department; and (c) responses will be used only for the necessary information to include in our Affirmative Action Program. We are a company that values diversity. We actively encourage women and minorities to apply. Refusal to provide this information will have no bearing on your application and will not subject you to any adverse treatment.

Please complete the information requested below. Thank you for your cooperation.

Definitions and Eligibility

According to 41 CFR 60-741.42, there are only two circumstances when an employer may ask a disabled applicant to self-identity on a pre-offer basis:

The invitation is made when the contractor actually is undertaking affirmative action for individuals with disabilities at the pre-offer stage
The invitation is made pursuant to a Federal, state or local law requiring affirmative action for individuals with disabilities.

According to 41 CFR 60-250.42, there are only two circumstances under which an employer may ask applicants who are Special Disabled Veterans to self-identity on a pre-offer basis:

The invitation is made when the contractor actually is undertaking affirmative action for special disabled veterans at the pre-offer stage
The invitation is made pursuant to a Federal, state or local law requiring affirmative action for special disabled veterans.

EEOC RACE/ETHNIC IDENTIFICATION CATEGORIES

Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
Caucasian/White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Black/African American: A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Other Pacific Islander: A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Asian: 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 Phillippine Islands, Thailand, and Vietnam.
American Indian or Alaska Native: 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.
Two or More Races: All persons who identify with more than one of the above five races.

DEFINITION OF "INDIVIDUAL WITH DISABILITIES": Individual with Disabilities Defined as a person who (1) has a physical or mental impairment which substantially limits one or more of his or her major life activity(s), (2) has a record of such impairment(s), or (3) is regarded as having such impairment(s). For purposes of this definition, an individual with disability(s) is a substantially limited if he or she is likely to experience difficulty in securing, retaining, or advancing in employment because of the disability(s).

VETERAN STATUS DEFINITIONS

Special Disabled Veteran Defined as a veteran who is entitled to disability compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Veterans Administration for a disability (I) rated at 30% or more, or (II) rated at 10 or 20% in the case of a veteran who has been determined under Section 1506 to have a serious employment disability, or a person who was discharged from active duty because of a service-connected disability.
Veteran of the Vietnam Era Defined as a veteran who (a) served on active duty in the Republic of Vietnam between February 28, 1961 and May 7, 1975, or (b) served on active duty for a period of more than 180 days, any part of which occurred between August 5, 1964 and May 7, 1975, and was discharged or released therefrom with other than a dishonorable discharge, or (c) was discharged or released from active duty for a service-connected disability if any part of his or her active duty was performed between August 5, 1964 and May 7, 1975.
Other Eligible Veteran Defined as any veteran who served in a "war" declared by Congress, in a campaign or on an expedition for which a campaign badge, a service medal, or an expeditionary medal has been awarded.

Race or Ethnicity

Gender

Female
Male
Prefer Not To Say

How did you hear about our openings?

What 3 goals would you like to achieve on your job?

What skills would you like for your job site supervisor to work with you on?

What are some likes/dislikes when it comes to a job?

Are you able to work in a fast pace work environment or would you prefer a quiet setting?

Fast Pace
Quiet Setting

Would you like to work outside or in a building?

Outside
In A Building

Are there any limitations to working such as not being able to lift more than 10 pounds, not being able to walk long distances, or not being able to stand for long periods of time?

Would you like a copy of this application emailed to you?

Yes
No

Employment Application Form

High School

College

Graduate School

Trade School/Other

Current Employer

Previous Employer 1

Previous Employer 2

References

Reference #1

Reference #2

Reference #3

Equal Opportunity Employer

Definitions and Eligibility