AG|CM Employment Application Step 1 of 616%It is the policy of AG|CM, Inc. to provide equal employment opportunities to all applicants and employees without regard to race, color, religion, gender, national origin, age, disability, veteran status, sexual orientation or any other legally protected status. In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire. * denotes a required field Applicant Information:First Name*MiddleLast Name*Mailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Datetime Phone*Evening Phone*Email Do you have a current/valid driver's license?* Yes NoJob Position Applying for*Position Full or Part time?*Full TimePart TimeWho referred you to our company?Are you legally eligible for employment in the United States?*YesNoHave you ever been convicted of a felony, public indecency or a violation of the Texas controlled substances act, or have you ever pled guilty or no contest to a criminal act, or have you been placed on probation or had your driver’s license suspended or revoked, or been notified of any exclusion or sanctioning by a federal program?*YesNoNote: A positive response to any part of the question will not necessarily bar you from being considered for employment. AG|CM will consider the offense for which you were convicted, the circumstances surrounding the conviction and the date of the conviction as important factors in making a hiring decision.If your answer to any of the above is “Yes”, please provide details, including dates below:Applicant Employment HistoryApplicant SkillsList any skills that may be useful for the job you are seeking. Enter the number of years of experience, and the number which corresponds to your ability for each particular skill. (1 = poor ability, while 5 = exceptional ability)SkillYears of ExperienceRating List your current or most recent employment first. Please list all jobs (including self-employment ) which you have held, beginning with the most recent, and list and explain any gaps in employment.Employer #1Employer Name*Dates of EmploymentFrom ( Month / Year):*To ( Month / Year):*Job Title*Job Duties*Supervisor NameAddress Street Address City State / Province / Region ZIP / Postal Code Phone*Reason for Leaving*Need Employer #2 Section?*YesNoEmployer #2Employer Name*Dates of EmploymentFrom date ( Month / Year)*To date ( Month / Year)*Job Title*Job Duties*Supervisor NameAddress Street Address City State / Province / Region ZIP / Postal Code Phone*Reason for Leaving*Need Employer #3 Section?*YesNoEmployer #3Employer Name*Dates of EmploymentFrom date (Month / Year)*To date (Month / Year)*Job Title*Job Duties*Supervisor NameAddress Street Address City State / Province / Region ZIP / Postal Code Phone*Reason for Leaving*Need Employer #4 Section?*YesNoEmployer #4Employer Name*Dates of EmploymentFrom date (Month / Year)*To date (Month / Year)*Job Title*Job Duties*Supervisor NameAddress Street Address City State / Province / Region ZIP / Postal Code Phone*Reason for Leaving*Need Employer #5 Section?*YesNoEmployer #5Employer Name*Dates of EmploymentFrom date (Month / Year)*To date (Month / Year)*Job Title*Job Duties*Supervisor NameAddress Street Address City State / Province / Region ZIP / Postal Code Phone*Reason for Leaving* Applicant Education and TrainingCollege/University Name and AddressDId you receive a degree?YesNoIf yes, degree(s) receivedHigh School / GED Name and AddressDid you graduate?YesNoOther Training (Graduate, Technical, Vocational)Please indicate any current professional licenses or certifications that you hold and any awards, honors or special achievements:Military ServiceYesNoMilitary Specialized Training Professional ReferencesPlease provide two professional references (former employer, manager, supervisor, or as a last resort, a co-worker) who can verify your experience and qualifications to perform the job you have applied for--- Professional Reference #1 ---Name*TitleContact Phone*CompanyDates of EmploymentFrom date (Month / Year)*To date (Month / Year)*Position you heldReason for leaving--- Professional Reference #2 ---Name*TitleContact Phone*CompanyDates of EmploymentFrom date (Month / Year)*To date (Month / Year)*Position you heldReason for leavingPlease provide any other information that you believe should be considered, including whether you are bound by any agreement with any current employer.Upload FilesUpload your resume*Accepted file types: pdf, doc, docx.Upload your cover letterAccepted file types: pdf, doc, docx.OptionalApplication StatementI certify that the answers given are true and complete to the best of my knowledge. I hereby certify that there are not willful misrepresentations, omissions or falsifications in the foregoing statements and answers to questions. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment as may be necessary in arriving at an employment decision.I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is an “at will” nature. This means that the employee may resign at any time and that the employer may discharge the employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless an authorized executive or this organization specifically acknowledges such change in writing.I am fully aware that my misrepresentations, omissions, or falsifications given in my application or interview(s) will be grounds for immediate rejection of my application, or if hired, termination of my employment. I understand, also, that I am required to abide by all rules and regulations of the employer, AG|CM, Inc.* I certifyDate Date Format: MM slash DD slash YYYY Applicant Self Identification FormVOLUNTARY INFORMATION: AG|CM Inc. is a government contractor, and to comply with the regulations for equal employment opportunity and affirmative action (EEO/AA), we must track applicants by gender, race/ethnicity, and the position they applied for. With this data, reports are prepared and submitted to various government agencies as part of AGCM’s affirmative action program. We value diversity and encourage women and minorities to apply for our vacant positions. For this reason, we invite you to report your status as a minority by indicating your gender and race/ethnicity below.Submission of this information is voluntary and refusal to provide it will not subject applicants to any adverse treatment. Responses will remain confidential within the Human Resources Department, and are kept separate from the employment application. The data is used only for required information included in AGCM’s Affirmative Action Program. When reported, data will not identify any specific individuals.First NameMiddleLast NameJob Position Applying forDate Date Format: MM slash DD slash YYYY Gender Male FemaleAre you Hispanic or Latino? Yes NoIf you answered "Yes" above, you have completed this form. If you answered "No", please continue. White (Not Hispanic or Latino) Black or African American (Not Hispanic or Latino) Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) Asian (Not Hispanic or Latino) American Indian or Alaska Native (Not Hispanic or Latino) Two or More Races (Not Hispanic or Latino) I do no wish to discloseDefinitions of race/ethnic categories Hispanic of 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. Voluntary Self-Identification of Veterans FormDefinitions This employer is a Government contractor subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications are defined as follows: A "disabled veteran” is one of the following:A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; orA person who was discharged or released from active duty because of a service-connected disability. A "recently separated veteran" means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service. An "active duty wartime or campaign badge veteran" means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense. An "Armed forces service medal veteran" means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985. Protected veterans may have additional rights under USERRA—the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor's Veterans Employment and Training Service (VETS), toll-free, at 1-866-4-USA-DOL. Self-Identification As a Government contractor subject to VEVRAA, we are required to submit a report to the United States Department of Labor each year identifying the number of our employees belonging to each specified “protected veteran” category. If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below. If you are not a veteran, select box 1 OR select the box(s) that apply to your veteran status.I am not a veteran or choose not to identify (choose one) I am not a veteran (I did not serve in the military) I am NOT a protected veteran. (I served in the military but do not fall into any veteran categories listed below) I choose not to identify my veteran statusI am a veteran and belong to the following classifications of protected veterans (Choose all that apply) DISABLED VETERAN RECENTLY SEPARATED VETERAN ACTIVE WARTIME OR CAMPAIGN BADGE VETERAN ARMED FORCES SERVICE MEDAL VETERANIf RECENTLY SEPERATED VETERAN, Military Discharge Date Date Format: MM slash DD slash YYYY First NameMiddleLast NameDate Date Format: MM slash DD slash YYYY Voluntary Self-Identification of Disability Form Why are you being asked to complete this form? Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities. To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. 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. Disabilities include, but are not limited to: Blindness Deafness Cancer Diabetes Epilepsy Autism Cerebral palsy HIV/AIDS Schizophrenia Muscular dystrophy Bipolar disorder Major depression Multiple sclerosis (MS) Missing limbs or partially missing limbs Post-traumatic stress disorder (PTSD) Obsessive compulsive disorder Impairments requiring the use of a wheelchair Intellectual disability (previously called mental retardation)Please check one of the boxes below: Yes, I have a Disability (or previously had a disability) No, I don't have a Disability I don't wish to answerFirst NameMiddleLast NameDate Date Format: MM slash DD slash YYYY 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 a sign language interpreter, or using specialized equipment. Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.CommentsThis field is for validation purposes and should be left unchanged.