Power Design

APPLICATION FOR EMPLOYMENT

Power Design, Inc. (the “Company”) considers all applicants for employment without regard to race, color, religion, sex, national origin, age, disability, or status as a Vietnam-era or special disabled veteran in accordance with federal law. In addition, the Company complies with applicable state and local laws prohibiting discrimination in employment. The Company also provides "reasonable accommodations" to qualified individuals with disabilities, in accordance with the Americans With Disabilities Act and applicable state and local laws.

Applications will remain on file for two years after receipt by the Company.
 

General Information
Today’s Date: Position Applied for:
Willing to Work Overtime? Yes      No   Date You Can Begin Work:
 

Personal Information
First Name:      Middle Name:      Last Name:  
Address:           City:      State:      Zip:  
Area Code/Telephone: Email Address:
Have you ever been employed with Power Design?  
Yes      No  
If yes, please give the dates of employment and under what name.
 Do you have relatives employed with Power Design?  
Yes      No  
If yes, please list name(s) below

Have you ever been convicted, plead no contest, or had adjudication withheld, for a felony?   Yes      No  

Have you ever been convicted, plead no contest, or had adjudication withheld, for an act of dishonesty, or breach of trust or moral turpitude, such as misdemeanor petty theft, burglary, fraud, writing of bad checks or violence such as battery, assault, etc.?   Yes      No  

If you answered yes, please provide details regarding the type of crime and/or nature of the tort, the date of the disposition, the penalty or penalties imposed, and the final disposition of the legal proceeding.

If you have answered yes to either of the two last questions, the answer(s) will not automatically prevent you from obtaining employment with Power Design. Your response will be considered by the Company together with other hiring factors and job relatedness.
 

Employment History
This section must be completed in full. Using "see resume" is not acceptable. Please list your employment history for the last ten years. Note any periods for which you were not employed.
Employer (Present or Most Recent) Street Address, City, State, Zip
Your Job Title Supervisor Name and Title
Description of Your Duties:
Time Period: Base Pay:
From (Mo/Yr)
To (Mo/Yr)
Starting $ Per
Final $ Per
Reason for Leaving:
May we contact you at your present place of employment?
Yes      No  
If yes, please enter Area Code/Telephone No.
 May we contact your present employer for references?
Yes      No  
If yes, please enter Area Code/Telephone No.


Employer (Previous) Street Address, City, State, Zip
Your Job Title Supervisor Name and Title
Description of Your Duties:
Time Period: Base Pay:
From (Mo/Yr)
To (Mo/Yr)
Starting $ Per
Final $ Per
Reason for Leaving:


Employer (Previous) Street Address, City, State, Zip
Your Job Title Supervisor Name and Title
Description of Your Duties:
Time Period: Base Pay:
From (Mo/Yr)
To (Mo/Yr)
Starting $ Per
Final $ Per
Reason for Leaving:


Employer (Previous) Street Address, City, State, Zip
Your Job Title Supervisor Name and Title
Description of Your Duties:
Time Period: Base Pay:
From (Mo/Yr)
To (Mo/Yr)
Starting $ Per
Final $ Per
Reason for Leaving:


Employer (Previous) Street Address, City, State, Zip
Your Job Title Supervisor Name and Title
Description of Your Duties:
Time Period: Base Pay:
From (Mo/Yr)
To (Mo/Yr)
Starting $ Per
Final $ Per
Reason for Leaving:
 

Occupational Skills

(List any that you believe are related to the job for which you are applying.)
(List any Oracle Software experience.)
 

Education

(If specific educational achievement is a requirement of the job for which you apply, credentials will be verified.)
Schools
Attended		 Name of School Major Field of Study Grade Point Average
(e.g. 3.2/4.0)		 Degree or
Diploma Received
High School
College
Graduate
Trade of
Technical
Other relevant education or training taken:
 

Driving Record

(Answer only if you will drive a Company vehicle or your own vehicle on Company business during your employment.)
Do you have a valid state driver’s license?   Yes      No  
What class license do you have?   Operator      CDL  
Have you had a suspension or probation of your license within the last five years?   Yes      No  
How many speeding or other moving violations have you received in the last three years?
 

References
List three persons familiar with your technical ability and work performance whom we may contact for reference (excluding relatives). We will assume we have your permission to contact these individuals unless you indicate to the contrary.
Name (Last, First, Middle) Address (City, State, Zip) Area Code/Telephone No.
 

Employment Eligibility Verification

Federal laws require that employers hire only individuals who are authorized to be lawfully employed in the United States. In compliance with such laws, the Company will verify the status of every person who is offered employment with the company. All offers of employment are subject to verification of the applicant's identity and employment authorization, and you will be asked to provide documents as are required by law to verify your identification and employment authorization upon employment.

In addition, we may, upon separate notice to and consent from you following a conditional offer of employment, conduct other background checks applicable to the job for which you are being considered.
 

Pre-Employment Statement
Please read the following statements carefully.
They constitute important conditions for employment with Power Design, Inc.
  1. The information that I have provided on this application is true and complete to the best of my knowledge. Any misrepresentation or omission of any fact in my application, resume, or any other materials, or during any interviews, can be justification of refusal of employment, or, if employed, termination from the Company’s employ.

  2. Any offer of employment I may receive from the Company is contingent upon my successful completion of the company's total pre-employment screening process, including the company's receiving references that it considers satisfactory, and my satisfactory completion of any post-offer pre-employment medical examination that the company may require.

  3. I understand that as a condition of employment, I will be required to undergo and successfully pass a screening for alcohol and/or drugs.

  4. I authorize and request that all of my present and former employers and those individuals I have listed as personal references furnish information about my employment record, including a statement of the reason for the termination of my employment, work performance, abilities, and other qualities pertinent to my qualifications for employment, hereby releasing them from any and all liability for damages arising from furnishing the requested information.

  5. In consideration of my employment, I agree to comply with the policies, rules, regulations, and procedures of the Company and understand that my employment is considered “at will” and can be terminated with or without cause or notice, at any time, at the option of either the Company or myself.

  6. WAIVER OF JURY TRIAL.  ALL PARTIES TO THIS AGREEMENT KNOW AND UNDERSTAND THAT THEY HAVE A CONSTITUTIONAL RIGHT TO A JURY TRIAL.  THE PARTIES HEREBY WAIVE ANY RIGHT TO TRIAL BY JURY IN ANY PROCEEDING ARISING OUT OF OR RELATING TO THIS AGREEMENT OR ANY OF THE CONTEMPLATED TRANSACTIONS, WHETHER NOW EXISTING OR HEREAFTER ARISING, AND WHETHER SOUNDING IN CONTRACT, TORT OR OTHERWISE.  THE PARTIES AGREE THAT ANY OF THEM MAY FILE A COPY OF THIS PARAGRAPH WITH ANY COURT AS WRITTEN EVIDENCE OF THE KNOWING, VOLUNTARY AND BARGAINED-FOR AGREEMENT AMONG THE PARTIES IRREVOCABLY TO WAIVE TRIAL BY JURY AND THAT ANY PROCEEDING WHATSOEVER BETWEEN THEM RELATING TO THIS AGREEMENT OR ANY OF THE CONTEMPLATED TRANSACTIONS SHALL INSTEAD BE TRIED IN A COURT OF COMPETENT JURISDICTION BY A JUDGE SITTING WITHOUT A JURY. BY THEIR SIGNATURES BELOW, THE PARTIES PROMISE, WARRANT AND REPRESENT THAT THEY WILL NOT PLEAD FOR, REQUEST OR OTHERWISE SEEK TO HAVE A JURY TO RESOLVE ANY AND ALL DISPUTES THAT MAY ARISE BY, BETWEEN OR AMONG THEM.

Power Design is an Affirmative Action/Equal Opportunity Employer
 

Applicant's Signature: