P O Box 458, 100 N. High St., Antlers, OK 74523, Phone 580-298-3368, Fax 580-298-3751 P O Box 960, 701 S. Mississippi, Atoka, OK 74525, Phone 580-889-7357, Fax 580-889-2266 P O Box 387, 704 S. Broadway, Coalgate, OK 74538, Phone 580-927-3555, Fax 580-927-1103 P O Box 609, 1501 E. Jackson, Hugo, OK 74743, Phone 580-326-4958, Fax 580-326-8225 P O Box 250, 100 Harper Valley Rd., Kiowa, OK 74553, Phone 918-432-3400

EMPLOYMENT APPLICATION NAME:

DATE:

ADDRESS:

CITY/STATE/ZIP:

EMAIL:

PHONE NUMBER:

Referral Source (please check the appropriate category and name the source): Advertisement

Company’s Website

Employee

Job Fair

School

Staffing Agency

Walk-In

Other___________

Section One (Personal/Position Related Information): Position/Location applied for: Please list any other name under which you have been employed: Are you authorized to work for any employer in the United States?

Yes

No

Have you ever been convicted of a felony? (Applicants are not obligated

Yes

No

to disclose sealed or expunged arrest or conviction records. A conviction will not necessarily disqualify an applicant from employment.)

If you answered yes to the above question, please explain: What are your preferred hours? Are you willing to work other hours? Are you available to work overtime?

Yes

What is your work preference?

Full Time

No Part Time

Seasonal

If applying for a position which would require you to drive a vehicle please list your Drivers License #:

1

EMPLOYMENT APPLICATION Section Two (Education): Education/Type

Name & City

Coursework Taken

High School

Did you Graduate? Yes / No

College

Yes / No

Graduate School

Yes / No

Other

Yes / No

Degree Received

Section Three (Work History): Please give your work history for the past 10 years. Note any gaps in employment. Begin with the most recent employer. Feel free to use additional paper if necessary.

1.

Company:

Phone Number:

Address:

City/State/Zip:

Job Title:

Dates Employed:

Beginning Salary:

Ending Salary:

Supervisor’s Name:

May we contact supervisor?

Yes

No

Yes

No

Reason for Separation:

2.

Company:

Phone Number:

Address:

City/State/Zip:

Job Title:

Dates Employed:

Beginning Salary:

Ending Salary:

Supervisor’s Name:

May we contact supervisor?

Reason for Separation:

2

EMPLOYMENT APPLICATION 3.

Company:

Phone Number:

Address:

City/State/Zip:

Job Title:

Dates Employed:

Beginning Salary:

Ending Salary:

Supervisor’s Name:

May we contact supervisor?

Yes

No

Reason for Separation:

Section Four (Additional Information): List any special achievements or qualifications (such as Training, etc.):

List any professional organization membership(s): Please exclude memberships that may reveal race, religion, age, creed, color, sex, national origin or other segmenting factor

Section Five (Application Verification/Acknowledgement): In completing this application, I verify that everything is true and accurate. Should I be granted a personal interview, I agree that information will be true as well. I understand that any false statements can lead to immediate termination. I understand that this application will only be considered for 45 days from the date I signed the document. Should I want to be considered after this time, I will need to reapply. Company Name has the right to verify any of this information with any former employer, motor vehicle department, criminal history, personal reference or educational institution. Company Name has the right to use outside agencies, as it deems necessary to verify this information and/or during the course of an investigation at any time prior to or during my employment. Should I be offered a job, I agree to comply with all policies (including drug testing) of Company Name I understand only the Director has the authority to make or change policies. I understand that Company Name is not obligated to provide employment and that I am not required to accept employment. Nothing in this application or in any prior or subsequent oral or written communication is intended to create any contract or employment. I agree to not record any interaction, materials within, or regarding Company Name, its employee and/or other interaction to which I may or may not be a party prior to, during or following my employment. Should there ever be litigation between my parties, Company Name, and myself I agree to utilize arbitration as a viable and binding alternative resolution. I am aware that Company Name is an equal opportunity employer. Company Name does not hire, promote, terminate or make any other employment decisions based on race, religion, age, creed, color, sex, national origin or other segmenting factor. Company Name is an at will employer and as such has the right to terminate employment at any time. Should I become employed, I have the same right to terminate my employment at any time.

Applicant Signature

Date

3

PreScreening Notice and Gertification Request for the Work Opportunity Gredit )

Information about Form

Job applicant:

88510

and its

OMB No. 1545-1500

instructions is at

below

any boxes that apply.

Your name

Social security number

only this side.

)

Street address where you live City or town, state, and ZIP code County

Telephone number

lf you are under age 40, enter your date of birth (month, day, year)

fl

Check here if you received a conditional certification from the state workforce agency (SWA) or a participating local agency for the work opportunity credit.

!

Ctrect< here if

any of the following statements apply to you.

o I am a member of a family that has received assistance from Temporary e

Assistance for Needy Families OAND for any 9 months during the past 18 months. I am a veteran and a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (food stamps) for at least a 3-month period during the past 15 months.

o I was referred here o

. o

'

by a rehabilitation agency approved by the state, an employment network under the Ticket to Work program, or the Department of Veterans Affairs. I am at least age'18 but not age 40 or older and I am a member of a family that: a Received SNAP benefits (food stamps) for the past 6 months, or b Received SNAP benefits (food stamps) for at least 3 of the past 5 months, but is no longer eligible to receive them. During the past year, I was convicted of a felony or released from prison for a felony. I received supplemental security income (SSl) benefits for any month ending during the past 60 days. I am a veteran and I was unemployed for a period or periods totaling at least 4 weeks but less than 6 months during the past year.

!

Check here if you are a veteran and you were unemployed for a period or periods totaling at least 6 months during the past

!

Check here if you are a veteran entitled to compensation for a service-connected disability and you were discharged or

year.

released from active duty in the U.S. Armed Forces during the past year.

n

Check here if you are a veteran entitled to compensation for a service-connected disability and you were unemployed for a period or periods totaling at least 6 months during the past year.

n

Cnect here if you are a member of a family that: o Received TANF payments for at least the past 18 months,

. .

or

Received TANF payments for any 18 months beginning after August 5, '1997, and the earliest 18-month period beginning after August 5, 1997, ended during the past 2 years, or

StoPped being eligible for TANF payments during the past 2 years because federal or state law limited the maximum time those payments could be made.

-Al

Applicants

Under p€nalties of perjury, I declare that I gave the above information to the employer on or before the day I was offer€d a iob, and it is, to the b€st of my knowl€dge, true, con€ct, and complete.

Job applicant's signature

)

For Privacy Act and Paperurork Reduction Act Notice, see page

Date

2,

cat. No.

22851L

Form

8850

(Rev. 1-2olg)

PRE-EMPLOYMENT VOLUNTARY QUESTIONNAIRE As an equal opportunity employer, we are obligated by Federal and State regulations to monitor our employment practices. To ensure the accuracy of this information, your assistance in this questionnaire will be greatly appreciated. Information concerning race, sex, or veteran’s status will not be used to discriminate against or give preference to any individual. This data will be kept separate from the personnel file and is used for statistical purposes only. Response is voluntary and answers will remain confidential. When reported, data will not identify any specific individual.

APPLICANT’S NAME: ________________________________ (Please print) SIGNATURE:

_________________________________ DATE: _____________

POSITION FOR WHICH YOU ARE APPLYING: _________________________________ Please complete the following information about yourself:

□ Male □Female

ETHNIC GROUP Person of Mexican, Puerto Rican, Cuban Central or South American, or other Spanish Culture or origin, regardless of race □ Yes □ No _________________________________________________________________________________ RACE □ White-Person having origins in any one of the original peoples of Europe, North Africa, or the Middle East. □ Black/African American (Not Hispanic or Latino)-Person having origins in any of the Black racial groups of Africa. □ American Indian or Alaskan Native (Not Hispanic or Latino)-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. □ Asian (Not Hispanic or Latino)-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 Hawaiian or Other Pacific Islander (Not Hispanic or Latino)-Person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.) □ Two or More Races (Not Hispanic or Latino)-All persons who identify with more than one of the above five races.

____________________________________________________________________________________ VETERANS OF THE VIETNAM ERA A veteran of the Vietnam Era is a person who: served on active duty for a period of more than 180 days, any part of which occurred between August 5, 1964 and May 7, 1975, and was discharged other than dishonorable; or was discharged or released from active duty for a service-connected disability if any part of such duty was performed August 5, 1964 and May 7, 1975.

Are you a veteran of the Vietnam Era?

□ yes

□ no

OTHER PROTECTED VETERAN An Other Eligible Veteran is defined as a veteran who served in a “war.” This group also includes those veterans who served in a campaign or on an expedition for which a campaign badge, a service medal, or an expeditionary medal has been awarded, which includes a number of military engagements.

□ yes

Are you an Other Eligible Veteran?

□ no

SPECIAL DISABLED VETERAN A special disabled veteran is (i) 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 Department of Veterans Affairs for a disability (A) rated at 30 percent or more, or (B) rated at 10 or 20 percent in the case of a veteran who has been determined under Section 38 U.S.C. 3106 to have a serious employment handicap or (ii) a person who was discharged or released from active duty because of a service-connected disability.

Are you a Special Disabled Veteran?

□ yes

□ no

NEWLY SEPARATED VETERAN Any veteran who served on active duty in the U.S. military, ground, naval or air service during the one-year period beginning on the date of such veteran's discharge or release from active duty.

Are you a newly separated Veteran?

□ yes

□ no

Voluntary Sef.ldentification of Disablllty Why are you being asked to complcte

^.

Fom cc-305

OMB controlNrmber 1250-0005 Expires r/3tJ2lt7 Pase 1of2

tljs fom?

Because we do business with the government, we must reach out to, hire, and proude equal opportunity to qualified people with disabilities.i To help us measure ho'd 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 tofill it out. lf you are applying for a job, any answer you give will be kept private and will not be used against you in any way. lf you already work for us, your answer will no{ be used against you inanyway. Because a persm may become disabled at any time, we are required to ask all of our emplc'yees to update their information every fiVe years. You may voluntarily self-identiry 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 .Isabalitt/? You are considered to have a disability if you have a physical or mental impairment or medical conditim that substantially limits a major life activity, or if you have a history or record of such an impairment or medical cm dition. Disabilities include, but are not limited to:

. Blindness . Autism . . Deafness . Cerebral palsy . r Cancer . HIV/AIDS . . Dabetes . Schizophrenia . . Epilepsy . Muscular

Bipdar

. Post-traumatic stress disorder (PTSD) o Obsessive compulsive disorder (MS) . lmpairments requiring the use of a wheelchair . Intellectual disability (preMously called mental or limbs retardatim)

disorder

depression

Major Multiple sclerosis Missing limbs partially missing

dyshophy

Please check one of the boxes belour

n

tr tr

YES, I HAVE A DISABIL|TY (or preMorsly had a disabitity) NO, I DON'T HAVE A DISABILITY

I DON'TWISH TO ANSWER

Your Name

Todays Date

Votuntary Self-ldentification of Disablllty

Folm CC-305 OMB control Number 1250-0005 Expires U3|nofl

P4e

2

ol2

Reasonabls Accommodatlon Notice Federal law requires employers to provide reasonable accommodatiqt to qualified individuals with disabilities. please tell us if 1ou require a reasonable accommodation toapplyfc a job orto perform yolr job. Examples of reasonable accornmodation 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.

rSection 503 ofthe Rehabilitation Act of 1973, as amended. Formore information aboutthis form ortheequal employment obligations of Federal contractors, visit the U.S. Department of Labor's Office of Federal Contract compliance Programs (oFCCP) \/ebsite at v*Miv.dol.oovlofcco. PUBLIC BURDEN STATEMENT: According to the Paper'$iork Reduction Act of 1995 no persons are required to respond to a collection of infurmation unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.