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Job Application

Employment Application Form

Midcon is an Equal Opportunity Employer. We encourage all qualified individuals to apply for employment. If you require accommodation to complete the application, testing or interview process, please contact the Human Resources Department.

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

Employment Desired

Select Job Type

Select Desired Shift

Date Available

MM slash DD slash YYYY

First Job Choice

Referred By

Referral Source

Pay Requirement

Education

High School Name

Diploma or Degree

Major, Subject, Award, etc.

TRADE OR BUSINESS SCHOOL

Trade or Business School

Years Attended

Diploma or Degree

Major, Subject, Award, etc.

COLLEGE

College/University Name

Years Attended

Diploma or Degree

Major, Subject, Award, etc.

Military Service

Branch of Service

From

MM slash DD slash YYYY

Rank

Service-Related Training or Duties

References:

List three people not related to you whom you have known at least one year.

Reference 1: Name

Address

Phone

Relationship

Reference 2: Name

Address

Phone

Relationship

Reference 3: Name

Relationship

Phone

Address

Work Experience

(Please list all work experience for the last ten years and your last three employers. Begin with your most recent employer attach additional as necessary)

Most Recent Employer

Job Title and Duties

Address

Street Address Address Line 2 City State ZIP Code

From

MM slash DD slash YYYY

Starting Salary

Ending Salary

Supervisor

First Last

Phone

Reason for leaving

Second Most Recent Employer

Job Title and Duties

Address

Street Address Address Line 2 City State ZIP Code

From

MM slash DD slash YYYY

Starting Salary

Ending Salary

Supervisor

First Last

Phone

Reason for leaving

Third Most Recent Employer

Job Title and Duties

Address

Street Address Address Line 2 City State ZIP Code

From

MM slash DD slash YYYY

Starting Salary

Ending Salary

Supervisor

First Last

Phone

Reason for leaving

Special Qualifications

History

Have you previously applied for employment at this company?

Yes

If yes please explain

Do you have any relatives employed by this company or by any competitors?

Yes

Please provide name(s), title(s) and company name(s).

Have you been charged or convicted of any misdemeanor or felony violating any law other than minor traffic offenses in the past ten years?

Yes

Please provide the reason for the conviction, the date, the city and state. A conviction record will not necessarily bar you from employment.

Please read and initial the following statements

Accurate Information

I certify that the information here and in my resume is true and complete. I understand that any incomplete, misleading or false information will disqualify my application or be cause for dismissal. I authorize the company to contact all references listed here and further investigate my work experience and qualification.

Initials(Required)

Conditions

I understand that any offer of employment is contingent on the company's satisfaction with my: 1) drug test results; 2) identification and work authorization documents; 2) references and 4) background check.

Initials(Required)

Employment At Will

I understand and agree that if I am hired my employment will be for no defined period and that it may be terminated by me or by the company at any time, with or without cause or notice. I also understand that the company may change my job responsibilities or change my position at its discretion. I further understand that these terms of employment cannot be changed, except in writing, signed by the company president.

Initials(Required)

Today's Date(Required)

MM slash DD slash YYYY

Midcon Cables Applicant Information Affirmative Action

Midcon Cables is a federal contractor (or subcontractor). As such, we are required to maintain demographic information about our applicants. We would appreciate your help in completing this form to ensure the accuracy of our information. This form is completely voluntary. It will be kept confidential, except as required to administer our Affirmative Action Plan.

Name

First Last

Date

MM slash DD slash YYYY

Job Objective

Referral Source

Gender

Male

Female

Race

Please mark one or more of the following categories that best describes your ethnic background. (The definitions are government terms.)

Race

Black - All persons having origins in any of the Black racial groups of Africa

Hispanic -All Persons of Mexican, Puerto Rican, Cuban or South American or other Spanish culture, regardless of race.

Asian - All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent or the Pacific Islands. This area includes, for example, China, Japan, Korea, the Philippine Islands and Samoa.

Native American - All persons having origins in any of the original peoples of North America and who maintain cultural identification through tribal affiliation or community recognition. Meets Bureau of Indian Affairs definition standards.

White - Not covered above.

Disability

How do you know if you have a disability? Click Here

Voluntary Self-Identification of Disability(Required)

Yes, I Have A Disability, Or Have A History/Record Of Having A Disability

No, I Don’t Have A Disability, Or A History/Record Of Having A Disability

I Don’t Wish To Answer

Please Explain

Veteran

What are the Veteran Classifications? Click Here

Voluntary Veteran Self-Identification(Required)

Disabled Veteran

Recently separated Veteran

Active duty wartime or campaign badge Veteran

Armed Forces service medal Veteran

I am not a protected Veteran

I decline to disclose my protected Veteran status

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