ADP RESOURCE® MODEL EMPLOYMENT APPLICATION

INSTRUCTIONS:

 Please detach this instruction page prior to giving the application form to the applicant.

 Please note that while ADP Resource® has made this model employment application and
accompanying supplements available in Word format, we generally advise against making
changes and therefore are unable to make any changes on your behalf. This form should
not be considered legal advice. Any changes made should be reviewed by your counsel.

 This employment application can be used by applicants for any position within your company.

CRIMINAL RECORD INFORMATION:

 Some states require employers to wait until late in the selection process to ask about convictions.
The policy rationale is that an employer is more likely to objectively assess the relevance of an
applicant’s conviction if it becomes known when the employer is already knowledgeable about the
applicant’s qualifications and experience. As a best practice, and consistent with applicable laws,
the Equal Employment Opportunity Commission (“EEOC” - the federal government agency that
enforces anti-discrimination laws) recommends that employers not ask about convictions on job
applications and that, if and when they make such inquiries, the inquiries be limited to convictions
for which exclusion would be job related for the position in question and consistent with business
necessity. For this reason, there are no criminal record inquiries included with this application.

 We strongly recommend that clients conduct appropriate criminal background checks on all
applicants after a contingent offer of employment has been extended. In addition, clients should
employ an individualized assessment when reviewing criminal history.

 The EEOC guidance is available on the EEOC website below:

http://www.eeoc.gov/laws/guidance/arrest_conviction.cfm

 For assistance in evaluating criminal history based on the EEOC guidance please contact your
Human Resource Business Partner

APPLICATION SUPPLEMENT FOR COMMERCIAL MOTOR VEHICLE DRIVER POSITIONS:

 A separate application supplement for commercial motor vehicle driver positions subject to U.S.
Department of Transportation (DOT) regulations along with a form template to request DOT
required safety performance history from previous employers is available on FormSource.
 EMPLOYMENT APPLICATION

(PLEASE PRINT AND COMPLETELY ANSWER ALL QUESTIONS)

Our Company fully subscribes to the principles of Equal Employment Opportunity. It is our policy to provide
employment, compensation, and other benefits related to employment based on qualifications, without
regard to race, color, religion, national origin, age, sex, veteran status, genetic information, disability, or any
other basis prohibited by federal, state or local law. In accordance with requirements of the Americans with
Disabilities Act and applicable state laws, it is our policy to provide reasonable accommodation upon
request during the application process to eligible applicants in order that they may be given a full and fair
opportunity to be considered for employment. As an Equal Opportunity Employer, we intend to comply fully
with applicable federal and State employment laws and the information requested on this application will
only be used for purposes consistent with those laws. To the extent required by applicable law, the
Company maintains a smoke- free workplace.

Applicants for positions in Rhode Island please note that the company is subject to Chapters 29-38 of Title
28 of the General Laws of Rhode Island and is therefore covered by the state's workers compensation law
unless this box is checked ☐

If the box is checked the following exemption applies: _____________________________________

DK / AMANS VALVE
COMPANY NAME: ________________________________________________________________

POSITION APPLIED FOR: ___________________________________ DATE: ____________

PERSONAL DATA

Salary expectations:

Name:

Last Middle First

Street Address:

City: State:_______________ Zip Code:

Telephone:

If you are under 18 years of age, please specify your age: ( This information will be used
only for child labor law purposes).

Are there any days, shifts or hours you will not work? ☐ Yes ☐ No
If yes, please explain:

Are you available for out of town work? ☐ Yes ☐ No

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Will you work overtime, if required? ☐ Yes ☐ No

When will you be able to start work? _________________________________________________

Have you ever been found at fault in a civil action for an intentional tort (intentional commission of

a wrongful act)? ☐ Yes ☐ No

Note: Answering “yes” does not automatically exclude you from further consideration for the position.

If yes, include nature of the intentional tort and the disposition of the action: _________________

_______________________________________________________________________________

_______________________________________________________________________________

How did you learn of our Company?

If referral, who were you referred by?

Have you ever applied or worked at our Company before? ☐ Yes ☐ No

If yes, provide dates: ______________________________________________________________

Are you legally authorized to work in the United States? ☐ Yes ☐ No

Will you now or in the future require sponsorship for employment visa status (e.g.,H-1B visa status)?
☐ Yes ☐ No

Note: The Federal Immigration and Reform and Control Act of 1986 requires that a DHS
Employment Eligibility Verification “Form I-9” be completed for every new hire and that within 3
business days of beginning work every new hire must present to the employer documentation
establishing his/her identity and authorization to work. This federal requirement must be satisfied as
a condition of employment.

DRIVING RECORD
(Answer only if driving is a requirement of the job for which you are applying).

Do you have a valid driver’s license? ☐ Yes ☐ No State: ________ License No:

Have you had any tickets? ☐ Yes ☐ No

If yes, please explain:

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

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EDUCATION
Describe any educational degrees, skills, training or experience you believe are relevant to the job applied for:

Graduated If no,
Name, City and State of Type of Degree
Degree Grade Point/
Educational Institution Received or Major Minor
Credits Overall GPA
Yes No Expected
Earned
High School

College or University

Technical/GED

Licenses/ Certification/
Other

EMPLOYMENT HISTORY:

Please complete for all full-time or part-time employment beginning with most recent employer. You may
include as part of your employment history any verified work performed on a volunteer basis. All applicants
should start with their most recent job, include active military assignments and voluntary employment and
provide ten (10) years of history. (A separate sheet may be attached.) You must explain any gaps in your
employment history.

Company Name: _____________________________________Telephone: ____________

Address: ________________________________________________________________________

Name of Supervisor: __________________________________May we contact: ☐ Yes ☐ No

Dates Employed: From: _________To: ___________Rate of Pay: Start: __________ Last: ____
State job titles and describe job duties: ________________________________________________
Reason for leaving: _______________________________________________________________

Company Name: _____________________________________Telephone: ____________

Address: ________________________________________________________________________

Name of Supervisor: __________________________________May we contact: ☐ Yes ☐ No

Dates Employed: From: __________To: ___________Rate of Pay: Start: __________ Last: ____
State job titles and describe job duties: ________________________________________________
Reason for leaving: _______________________________________________________________

Company Name: _____________________________________Telephone: ____________

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Address: ________________________________________________________________________

Name of Supervisor: __________________________________May we contact: ☐ Yes ☐ No

Dates Employed: From: __________To: ___________Rate of Pay: Start: __________ Last: ____
State job titles and describe job duties: ________________________________________________
Reason for leaving: _______________________________________________________________

Company Name: _____________________________________Telephone: ____________

Address: ________________________________________________________________________
Name of Supervisor: __________________________________May we contact: ☐ Yes ☐ No
Dates Employed: From: __________To: ___________Rate of Pay: Start: __________ Last: ____
State job titles and describe job duties: ________________________________________________
Reason for leaving: _______________________________________________________________

Please explain any gaps in your employment history: _______________________________

__________________________________________________________________________

Have you ever been discharged or forced to resign? ☐ Yes ☐ No

If yes, explain: ______________________________________________________________

__________________________________________________________________________

Did you receive any discipline in your last 12 months of active employment with your previous employer?
☐ Yes ☐ No If yes, please explain: __________________________________________________
__________________________________________________________________________

Were you given a performance evaluation within the last 12 months of active employment? ☐ Yes ☐ No
If yes, what was the range of scores used and what was your score? ___________________

__________________________________________________________________________

Have you signed any non-competition or non-solicitation agreement with any other employer that might
restrict you from working for this company (you may be required to furnish a copy of the agreement)?
☐ Yes ☐ No
If yes, please explain: ________________________________________________________

__________________________________________________________________________

REFERENCES (Please list three persons not related to you who know your qualifications.)

NAME ADDRESS PHONE RELATIONSHIP

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MILITARY (Complete only if you served in the military.)
Branch of Service: _______________________________Number of Years /Months of Service: ____
Rank at Discharge;______________________________Date of Discharge: ___________________
Reason for Leaving: ______________________________________________________________
Describe any military skills, training or experience you believe are relevant to the job you applied for:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

LIE DETECTOR TESTS

Massachusetts Applicants Note: 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.

Maryland Applicants Note: An employer may not require or demand, as a condition or prospective
employment or continued employment, an individual submit to or take a lie detector or similar test. An
employer who violates this law is guilty of a misdemeanor and subject to a fine not exceeding $100. I
have read and acknowledge this notice:

Applicant’s Signature: ______________________________________________________________

APPLICANT’S ACKNOWLEDGMENT

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I certify that the answers given herein (including but not limited to the Commercial Motor Vehicle Driver
Supplement if applicable) are true and complete to the best of my knowledge. I understand that any
misrepresentations, omissions of facts or incomplete answers in any application document may disqualify
me from further consideration for employment. I further understand that, if employed, any
misrepresentations or omissions of facts in any application document may be cause for my dismissal at
any time without prior notice.

I consent to and authorize this Company to contact my former employers,

references, and any and all other persons and organizations for information
bearing upon my qualifications for employment. I further authorize the listed
employers, schools and personal references to give the Company (without further
notice to me) any and all information about my previous employment and
education, along with any other pertinent information they may have and hereby
waive any actions which I may have against either party(ies) for providing a good
faith reference.

I EXPRESSLY AGREE AND UNDERSTAND THAT, IF EMPLOYED, MY EMPLOYMENT IS NOT FOR A

SPECIFIC TERM, IS BASED ON MUTUAL CONSENT AND MAY BE TERMINATED BY ME OR MY
EMPLOYER WITH OR WITHOUT NOTICE OR CAUSE AT ANY TIME. I FURTHER UNDERSTAND THAT
NO ORAL PROMISE, EMPLOYER POLICY, CUSTOM, BUSINESS PRACTICE OR OTHER PROCEDURE
(INCLUDING THE BASIC EMPLOYMENT POLICIES, PERSONNEL HANDBOOK OR ANY PERSONNEL
MANUALS) CONSTITUTE AN EMPLOYMENT CONTRACT OR MODIFICATION OF THE AT-WILL
EMPLOYMENT RELATIONSHIP BETWEEN ME AND THE EMPLOYER. I ALSO UNDERSTAND THAT
THIS ASPECT OF MY EMPLOYMENT MAY NOT CHANGE ABSENT AN INDIVIDUAL WRITTEN
AGREEMENT SIGNED BY BOTH ME AND THE PRESIDENT OF THE COMPANY.

I understand that applicants for certain positions may be required to qualify for employment based on
additional employment criteria. For example, I may be required to take job-related tests; take a driver’s
examination; submit to a background investigation or take a pre-employment drug test. If I am offered
employment or start work before any required test is completed, my employment is contingent on a
satisfactory result on all required tests. I authorize the release of any background check results and of
any drug/alcohol test to any state or federal authority requesting such information and in response to a
valid subpoena or other legal document.

CALIFORNIA APPLICANTS ONLY: I understand the Company may obtain, without using the services of
a third party investigative consumer reporting agency, public records pertaining to my character, general
reputation, personal characteristics or mode of living during its evaluation of my application for
employment and, if employed, during my employment. By checking the following box, I waive my right to
receive copies of public records obtained by the Company. ☐

Signature: ______________________________________ Date: _______________

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