AMP ELECTRICAL, INC.

APPLICATION FOR EMPLOYMENT

AMP ELECTRICAL, INC IS AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER

It is the policy of Amp Electrical, Inc to afford equal employment opportunity to all qualified persons regardless of race, color, religious creed, national origin, age, military status, sexual orientation, disability, genetic information, gender identity, gender expression or gender unless based upon a bona fide occupational qualification.

Personal Information

First Name

Middle Name

Last Name

Home Telephone Number

Personal Cell Phone Number

Email Address

Mailing Address

Street

City

State

Zip Code

Home Address - if different from mailing address

Street

City

State

Zip Code

Are you authorized to work in the U.S. on an unrestricted basis?

Yes No

Are you 18 years or older?

Yes No

Who referred you to this company?

Current Employee Employment Agency Newspaper advertisement Internet job site Friend Walk In Other

EMPLOYMENT DESIRED

Position Applied For

How soon can you start if a job offer is made?

Have you worked for Amp Electrical, Inc. before?

Yes No

Date

If Yes; Reason for Leaving:

Starting salary desired

Have you reviewed the essential functions of the job as listed on the job posting?

Yes No

In addition to your work history, what other experiences, skills or qualifications would qualify you for this work?

EDUCATION
(High School, College and/or Trade School)

Name of School

City

State

Main Course of Study

Did you Graduate

Degree

Years Attended

Name of School

City

State

Main Course of Study

Did you Graduate

Degree

Years Attended

Name of School

City

State

Main Course of Study

Did you Graduate

Degree

Years Attended

Name of School

City

State

Main Course of Study

Did you Graduate

Degree

Years Attended

List any additional education or training

PROFESSIONAL REFERENCES
List 3 people not related to you who can comment on your work performance.

Reference Name

Reference Address

Occupation

Telephone Number

Years Acquainted

Reference Name

Reference Address

Occupation

Telephone Number

Years Acquainted

Reference Name

Reference Address

Occupation

Telephone Number

Years Acquainted

COMPLETE ALL INFORMATION IN FULL. All applicants must complete this page even if they are also submitting a resume. BEGIN WITH YOUR MOST RECENT EMPLOYMENT, INCLUDING ANY PRESENT EMPLOYMENT. YOUR PRESENT EMPLOYER WILL NOT BE CONTACTED WITHOUT YOUR PERMISSION. YOU MAY INCLUDE ANY VERIFIABLE WORK PERFORMED ON A VOLUNTEER BASIS. ANY GAPS IN EMPLOYMENT MUST BE BRIEFLY EXPLAINED

EMPLOYMENT HISTORY

Are you employed now?

Yes No

If so may we inquire of your present employer?

Yes No

Company Name

Telephone

May we contact?

Yes No

Street Address

City

State

Zip Code

Job Title

Supervisor

Dates Employed From:

Dates Employed To:

Specific Duties

Reason for Leaving

Company Name 2

Telephone

May we contact?

Yes No

Street Address

City

State

Zip Code

Job Title

Supervisor

Dates Employed From:

Dates Employed To:

Specific Duties

Reason for Leaving

Company Name 3

Telephone

May we contact?

Yes No

Street Address

City

State

Zip Code

Job Title

Supervisor

Dates Employed From:

Dates Employed To:

Specific Duties

Reason for Leaving

Company Name 4

Telephone

May we contact?

Yes No

Street Address

City

State

Zip Code

Job Title

Supervisor

Dates Employed From:

Dates Employed To:

Specific Duties

Reason for Leaving

Applicants with Professional Licenses should complete and submit this form.
CERTIFICATIONS AND LICENSES

List any professional licenses, registrations or certifications you possess.

License

License Number

Date Issued

State Issued

Expiration Date

License

License Number

Date Issued

State Issued

Expiration Date

License

License Number

Date Issued

State Issued

Expiration Date

License

License Number

Date Issued

State Issued

Expiration Date

I understand that the foregoing will be verified in order to expedite my application for employment with Amp Electrical, Inc. I hereby authorize Amp Electrical, Inc to conduct a full investigation into my background, and as part of this investigation, my personal identifying information may be transmitted to a third-party performing the investigation.

I authorize Amp Electrical, Inc to obtain my previous work records, employment records, education, certification, professional licenses, driver’s license and history (if job related), professional references and any other information concerning knowledge, skills, and abilities and all other necessary information. Further I grant authority to the keeper of these records to release said records to Amp Electrical, Inc for the purpose of making its hiring decision.

I agree that the Amp Electrical, Inc shall not be liable in any respect if a job offer is not extended, is withdrawn, or my employment is terminated because of false statements, omissions or answers made by me on this application. I agree that my previous employers shall not be liable with regard to any information provided by them in connection with this release.

I certify under the pains and penalties of perjury that all statements made by me on this application are true and complete to the best of my knowledge and that I have withheld nothing, which, if disclosed, would affect this application unfavorably. I understand that any false statements, omissions or answers made by me on this application can result in my immediate termination.

In compliance with the Immigration and Reform and Control Act of 1986, I understand that after I accept the job offer and no later than my first day of work, I must complete and sign I-9 form, Section 1 Employee Information and Attestation. I understand that I will be required to provide approved documentation that verifies my right to work in the United States within 3 business days of my first day of employment. I have received the list of approved documents with this application.

Through this application, HR collects a range of highly personal information voluntarily provided by users. Unless otherwise required by law (including public records law), HR will use this information solely for hiring, payroll, and other human resources purposes. HR also makes this information available to other agencies or entities that are part of Amp Electrical, Inc, but will require any entity receiving this information to agree to the same restrictions on its use.

Victims of domestic violence, sexual assault, rape, or stalking and victims of an adjudicated crime may request that their information remain private by submitting a Public Records Exemption Form to their Domestic Violence Coordinator.

I understand that unless I attain permanent status pursuant to MGL Chapter 31 or am subject to the terms of a collective bargaining agreement and have completed the requisite probationary period, my employment will be at-will, which means that both Amp Electrical, Inc and I are free to terminate the employment relationship at any time for any non-statutorily prohibited reason or for no reason at all, with or without notice.

I hereby acknowledge that I have read in full and understand the above statements and conditions of employment

Printed Name

Date

Signature of Applicant

“It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.” MGL Ch.149, Section 19B