"*" indicates required fields

Personal Information

Name:*

First Middle Last Maiden or Other Names Used

Present Address:*

Street Address City State ZIP Code

Permanent Address:

Street Address City State ZIP Code

Primary Phone*

Secondary Phone

Are you at least 18 years or older?*

Yes

Do you possess the credentials to be legally employed in the United States?*

Yes

Employment Desired

Position applied for:*

Start Date:

Desired hourly wage:

Are you employed now?

Yes

Shift preference:

First 7am - 3pm

Second 3pm - 11pm

Third 11pm - 7am

Have your ever worked here before?

Yes

If so, when and in what department?

Referred by:

Employment wanted:

Full Time

Part Time

Seasonal / Temporary

Education

Please include name and location of school, field of study, and years attended.

High School/HSED:

Did you graduate:*

Yes

College:

Did you receive a degree:*

Yes

Trade/Tech School:

Did you receive a degree or certificate:*

Yes

Special Studies or Activities including Athletics, Civic and Volunteer:

U.S. Military or Reserve

Yes

Branch:

Highest Rank:

Honorable Discharge:

Yes

Active

Do you have any special skills, trainings, or certifications that would be advantageous to hiring you?*

Yes

If yes, give details:

References

(work or personal)

Name

City/State

Phone

Years known

Relation

click the + button on the right to add additional references

Work History

Employer:

Position held:

Address:

Street Address Address Line 2 City State ZIP Code

Employed From:

Employed To:

Job duties:

Reason for leaving:

May we contact this employer for reference?

Yes

Phone

Employer:

Position held:

Address:

Street Address Address Line 2 City State ZIP Code

Employed From:

Employed To:

Job duties:

Reason for leaving:

May we contact this employer for reference?

Yes

Phone

Employer:

Position held:

Address:

Street Address Address Line 2 City State ZIP Code

Employed From:

Employed To:

Job duties:

Reason for leaving:

May we contact this employer for reference?

Yes

Phone

** I authorize an inquiry to be made on the information contained in this application when it is used in consideration of determining employment. Former employers and listed references are authorized to give information regarding my employment. They are hereby released from any and all liability for issuing such information that is true and honorable. I understand that if any information is false or contains misrepresentations, my application may be rejected and if I am employed, my employment may be terminated at any time.

Signed:*

Applicant Drug/Alcohol Use and Consent To Post-Offer Drug & Alcohol Testing

After an offer of employment has been extended by Behrens Manufacturing, LLC (the “Company”), I must undergo a drug screen designed to identify whether or not I use/have used any controlled substances. This drug screen will be administered by a certified clinic or lab selected by the Company. All offers of employment with the Company are contingent on a negative drug test and/or alcohol test. Should a positive test result exist, my offer of employment will be automatically rescinded by the Company, unless I submit documentation supporting the legitimate use for a specific drug or the specific drug that resulted in a positive determination. This documentation must be made either prior to or within 3 business days after the positive drug result is communicated to me. If I test positive, I may request a confirmatory test of the original sample within 5 business days of receiving the initial positive test results of my drug and/or alcohol test. I understand that if I request a confirmation test, I will be responsible for paying the costs of this test. I also understand and agree that should I refuse to consent to a test or receive a confirmed positive test for the use of a controlled substance or alcohol, I will not commence work for the Company and the job offer will be automatically be rescinded. My employment is expressly conditioned on the successful passage of the pre-employment drug screen. I authorize the collection site, laboratory and/or medical review officer retained by the Company to perform any and all functions which those entities and/or individuals may be required to perform pursuant to this program or applicable regulations. Such authorization shall include, but is not limited to, the release of the result information to the Company, verification of the use of prescribed medications, obtaining information from the employee’s physician, hospital, dentist or pharmacist and the reporting of negative test results with a qualifying statement in cases wherein an employee may be taking a legally prescribed drug. I hereby release and hold harmless the Company and its employees and agents from any liability whatsoever arising from the Program.*

I understand and acknowledge this statement.

EEO-1 Voluntary Self Identification Form

The Equal Employment Opportunity Commission (EEOC) requires all private employers with 100 or more employees as well as federal contractors and first-tier subcontractors with 50 or more employees AND contracts of at least $50,000 complete an EEO-1 report each year. Covered employers must invite employees to self-identify gender and race for this report.

Completion of this form is voluntary and will not affect your opportunity for employment, or the terms or conditions of your employment. This form will be used for EEO-1 reporting purposes only and will be kept separate from all other personnel records only accessed by the Human Resources department. Please return completed forms to the HR department.

If you choose not to self-identify your race/ethnicity at this time, the federal government requires Behrens Manufacturing, LLC to determine this information by visual survey and/or other available information.

Gender

Male

Female

Race/Ethnicity

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 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.

Native American 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 maintains 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.

I do not wish to disclose.

Please check one of the descriptions below corresponding to the ethnic group with which you identify.

Voluntary Self-Identification of Disability and Veteran Status

Why are you being asked to complete this form?

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.

Please select one of the options below:

Yes, I have a disability (or previously had a disability)

No, I do not have a disability

I do not wish to answer

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 an interpreter, or using specialized equipment.

Veteran Status

I identify as a Protected Veteran

I do not identify as a Protected Veteran

I do not wish to answer

Pre-Employment Inquiry Authorization Release

I understand that an investigative report may be generated on me that may include information as to my character, general reputation, personal characteristics, or mode of living; work habits, performance or experience, along with reasons for termination of past employment/professional license or credentials; financial/credit history; or criminal/civil/driving record history. I understand that Behrens Manufacturing, LLC or its authorized agents may be requesting information from public and private sources about any of the information noted earlier in this paragraph in connection with Behrens Manufacturing, LLC's consideration of me for employment, promotion or position re-assignment or contract now, or at any time during my tenure with Behrens Manufacturing, LLC and give my full consent for this information to be obtained.
I acknowledge that a telephonic facsimile (FAX) or photographic copy of this release shall be as valid as the original. This release is valid for most federal, state and county agencies.
I understand that if I am a resident of Minnesota or Oklahoma (only) I may obtain a copy of the report ordered, and now indicate my desire to do so by checking this box:
I hereby authorize, without reservation, any financial institution, law enforcement agency, information service bureau, school, employer or insurance company contacted by Behrens Manufacturing, LLC or our authorized agents, to furnish the information described in Section I.

Current Address Since:

Mo/Yr

Street

City

State/Zip

The following information is required by law enforcement agencies and other entities for positive identification purposes when checking public records. It is confidential and will not be used for any other purposes.

Date of Birth - Month & Day only*

Social Security Number - Last 4 Digits only*

Name as it appears on Driver's License

Driver's License State

FAIR CREDIT REPORTING ACT NOTICE:
In accordance with the Fair Credit Reporting Act (FCRA, Public Law 91-508, Title VI), this information may only be used to verify a statement(s) made by an individual in connection with legitimate business needs. The depth of information available varies from state to state. Status of updates are available on request. Although every effort has been made to assure accuracy, backgroundchecks.com cannot act as guarantor of information accuracy or completeness. Final verification of an individual’s identity and proper use of report contents are the user's responsibility. Our authorized agent, PeopleScanner.com, has a policy that requires purchasers of these reports to have signed a Service Agreement. This assures PeopleScanner.com that users are familiar with and will abide by their obligations, as stated in the FCRA, to the individuals named in these reports. If information contained in this report is responsible for the suspension or termination of an employee or the application process, have the Candidate/employee contact PeopleScanner.com at 190 Haverhill Street, Methuen, MA 01844.

NOTICE TO CALIFORNIA CANDIDATES

Under section 1786.22 of the California Civil Code, you may view the file maintained on you during normal business hours. You may also obtain a copy of this file upon submitting proper identification. You may also receive a summary of the file by telephone. The agency is required to have personnel available to explain your file to you and the agency must explain to you any coded information appearing in your file. If you appear in person, a person of your choice may accompany you, provided that this person furnishes proper identification.

You have a right to obtain a copy of any consumer report or investigative consumer report obtained by Behrens Manufacturing, LLC by checking the box provided below. The report will be provided to you within (3) business days after we receive the requested reports related to the matter investigated.

I request to receive a free copy of this report by checking this box.

Employment Application

Please fill in as many fields as possible.

Personal Information

Employment Desired

Education

References

Work History

Applicant Drug/Alcohol Use and Consent To Post-Offer Drug & Alcohol Testing

EEO-1 Voluntary Self Identification Form

Voluntary Self-Identification of Disability and Veteran Status

Pre-Employment Inquiry Authorization Release

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