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Employment Application – Roebbelen
Send the completed forms to Angela Mills at Angelam@roebbelen.com or fax to (916) 358-5309.
Click here to download the form to your computer.
We drug test all our employees.
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An Equal Opportunity Employer
Please Print
______ _________ ____ _______
Date First Name Middle Last
Present Address
_____________________________________________ ________-____
No. & Street City State Zip
Permanent Address (if different from present address)
_____________________________________________ ________-____
No. & Street City State Zip
(___) ___-____ (___) ___-____
Business Phone Home Phone
Employment Desired
Position applying for: ______________________________________________
Personal Information
Have you ever applied to or worked for Roebbelen before?
Yes No
If yes, when? ___________________________________
Do you have any friends or relatives working for Roebbelen?
Yes No
If yes, state name(s) and relationship:
________________________________________ _______________
Name Relationship
Are you at least 18 years old? (If under 18, hire is subject to verification that you are of
minimum legal age.) Yes No
If hired, can you present evidence of your U.S. citizenship or proof of your legal right to live
and work in this country? ........................................................................................................................... Yes No
Are you able to perform the essential functions of the job for which you are applying, either
with or without reasonable accommodation? .........................................................................................
Yes No
Roebbelen Employment Application – Page 2
If no, describe the functions that cannot be performed.
____________________________________________________________
____________________________________________________________
(Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Hire may be subject to passing a medical examination, and to skill and agility tests.)
Have you ever been convicted of a criminal offense (felony or serious misdemeanor)? (Convictions for
marijuana-related offenses that are more than two years old need not be listed.)............................. Yes No
If yes, state nature of the crime(s), when and where convicted, and disposition of the case.
____________________________________________________________
____________________________________________________________
(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The nature of the offense, date of the offense, the surrounding circumstances, and the relevance of the offense to the position(s) applied for may, however, be considered.)
Education, Training and Experience
School Name and Address years completed Graduate? Degree or Diploma
High _________________________________ Yes No __________
School Name
______________________________
Address
_______________ ___ _____-____
City State Zip
College/ _________________________________ Yes No __________
University Name
______________________________
Address
_______________ ___ _____-____
City State Zip
Vocational/ _________________________________ Yes No __________
Business Name
______________________________
Address
_______________ ___ _____-____
City State Zip
Employment History
List below all present and past employment starting with your most recent employer (last five years is sufficient). Account for all periods of unemployment. You must complete this section even if attaching a resume.
______________________________(___) ___-____
Name of Employer Telephone No.
______________________________ ______________________________
Type of Business Your Supervisor's Name
_____________________________________________________-____
Address & Street City State Zip
Dates of Employment: __________ __________ Weekly Pay:__________ __________
From To Starting Ending
Employment Application – Page 3
____________________________________________________________
Your Position and Duties
____________________________________________________________
Reason for Leaving
May we contact this employer for a reference? ...................................................................................... Yes No
______________________________(___) ___-____
Name of Employer Telephone No.
______________________________ ______________________________
Type of Business Your Supervisor's Name
_____________________________________________________-____
Address & Street City State Zip
Dates of Employment: __________ __________ Weekly Pay:__________ __________
From To Starting Ending
____________________________________________________________
Your Position and Duties
____________________________________________________________
Reason for Leaving
May we contact this employer for a reference? ...................................................................................... Yes No
Note: Attach additional page(s) if necessary.
References
List below three persons not related to you who have knowledge of your work performance within the last three years.
___________________ ___________________ (___) ___-____
First Name Last Name Telephone No.
________________________________________________ _____-____
Address & Street City State Zip
_____________________________ ___
Occupation No. of Years Acquainted
___________________ ___________________ (___) ___-____
First Name Last Name Telephone No.
______________________________ _______________ ___ _____-____
Address & Street City State Zip
_____________________________ __
Occupation No. of Years Acquainted
___________________ ___________________ (___) ___-____
First Name Last Name Telephone No.
______________________________ _______________ ___ _____-____
Address & Street City State Zip
_____________________________ __
Occupation No. of Years Acquainted
Employment Application – Page 4
Please Read Carefully, Initial Each Paragraph and Sign Below
______ I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for
Initials employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on 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.
______ I hereby authorize Roebbelen to thoroughly investigate my references, work record, education and other matters
Initials related to my suitability for employment and, further, authorize the references I have listed to disclose to the company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the Company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.
______ I understand that nothing contained in the application, or conveyed during any interview which may be granted or
Initials during my employment, if hired, is intended to create an employment contract between me and the Company. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or the Company and that no promises or representations contrary to the foregoing are binding on the Company unless made in writing and signed by me and the Company’s designated representative.
_____
Initials Should a search of public records (including records documenting an arrest, indictment, conviction, civil judicial action, tax lien or outstanding judgment) be conducted by internal personnel employed by the Company. I am entitled to copies of any such public records obtained by the Company unless I mark the check box below. If I am not hired as a result of such information, I am entitled to a copy of any such records even though I have checked the box below.
I waive receipt of a copy of any public record described in the paragraph above
_______ ____________________________________________________________________
Date Applicant’s Signature
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Equal Employment Opportunity Data
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Date
To be completed by applicant:
Completion of this form is entirely voluntary, and all information will remain confidential and will not affect your application for employment. We are required by law to collect this information for equal opportunity employment purposes, and it will not become part of your personnel record if you are hired by this company.
Name: ________________________________________
Sex: Male Female
Race/Ethnicity: American Indian/Alaskan Native
Asian
Black /African American
Hispanic/Latino
Native Hawaiian/Pacific Islander
White
Two or more races
Government contractors must take affirmative action to employ and advance certain qualified individuals subject to the Rehabilitation Act of 1973 and the Vietnam Era Veterans Readjustment Act of 1974. Completion of the following information is voluntary, and will assist us in proper placement and reasonable accommodation. If you wish to be identified as qualifying for such placement or accommodation, please check where applicable:
Vietnam Era Veteran
Disabled Veteran
Individual with a Disability
To be completed by employer:
EEO-1 Category: 1. Executive/Sr. Officials & Managers 6. Administrative Support
2. First/Mid Officials & Managers 7. Craft Workers
3. Professionals 8. Operatives
4. Technicians 9. Laborers & Helpers
5. Sales Workers 10. Service workers
Employer information completed by:
_______________________________________ __________
Name Date
RACE AND ETHNIC IDENTIFICATION DEFINITIONS
Race and ethnic designations as used by the Equal Employment Opportunity Commission do not denote scientific definitions of anthropological origins. Definitions of the race and ethnicity categories are as follows:
Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
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 Philippine Islands, Thailand, and Vietnam.
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.
Two or More Races (Not Hispanic or Latino) - All persons who identify with more than one of the above five races.
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