Employment Application

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Step 1 of 11

Position(s) applying for
Date
Personal Data
Name
First Middle Last
Current Address
Street Address Address Line 2 City State ZIP Code
Prior Address
Street Address Address Line 2 City State ZIP Code
Cell Phone Number
Home Phone Number
Message Phone
Date Available to Start
Email Address

General Information
Have you ever been employed by Harrison Electrical, Inc.?
- Yes
- No
If yes, date(s) employed & reason for leaving?
Are you a citizen of the United States or otherwise eligible for employment in the United States?
Proof of identity and eligibility to work in the United States will be required prior to beginning employment.
- Yes
- No
Are you at least 18 years of age?
If no, employment is subject to verification of minimum legal age.
- Yes
- No

Education
Please provide the following information about each high school, technical school, college and occupational training program you have attended, beginning with the most recent. Attach additional documents at the end of this form if necessary. List seminars, workshops and employer sponsored training in the Additional Training section below. You may attach a resume instead of completing this section so long as the resume includes all of the information requested.
1. School
School Name
School Address
Major or Course of Study
# of Years Attended
Degree or Diploma
2. School
School Name
School Address
Major or Course of Study
# of Years Attended
Degree or Diploma
3. School
School Name
School Address
Major or Course of Study
# of Years Attended
Degree or Diploma
4. School
School Name
School Address
Major or Course of Study
# of Years Attended
Degree or Diploma

Employment History
Please provide the following information for all of your prior employers since you finished school, beginning with your most recent employer. List all periods of unemployment since you finished school. Attach additional documents at the end of this form if necessary. You may attach a resume instead of completing this section so long as the resume includes all of the information requested.
Are you currently employed?
- Yes
- No
If yes, may we contact your present employer?
- Yes
- No
1. Employer
Name of Employer
Address
Street Address Address Line 2 City State ZIP Code
Start Date
End Date
Title / Duties
Supervisor's Name and Title
Telephone Number
Reason for Leaving
2. Employer
Name of Employer
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Start Date
End Date
Title / Duties
Supervisor's Name and Title
Telephone Number
Reason for Leaving
3. Employer
Name of Employer
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Start Date
End Date
Title / Duties
Supervisor's Name and Title
Telephone Number
Reason for Leaving
4. Employer
Name of Employer
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Start Date
End Date
Title / Duties
Supervisor's Name and Title
Telephone Number
Reason for Leaving
Time Period of Unemployment
Please list dates and reason for unemployment below.

Additional Training
Please describe any additional training or professional development you have received, beginning with the most recent. Attach additional documents at the end of this form if necessary. You may attach a resume instead of completing this section so long as the resume includes all of the information requested.
1. Program
Name & Description of Program
Program Sponsor
Address
Street Address Address Line 2 City State ZIP Code
Start Date
End Date
Certification Received
2. Program
Name & Description of Program
Program Sponsor
Address
Street Address Address Line 2 City State ZIP Code
Start Date
End Date
Certification Received

Military Service
Branch of Service
Rank Achieved
Start Date
End Date
Type of Discharge
Where Served
Specialty

Additional Information
Do you have any licenses or certifications which are relevant to the position for which you are applying?
Please describe.
Have you ever been listed by any other name on education, military, employment or other records?
Please list all your names and the dates when they applied in a document attached at the end of this form.
- Yes
- No
Have you ever been discharged/fired or requested to resign from a position?
- Yes
- No
If so, please explain:
Why do you desire to make a change in employment?
Will you work overtime or non-traditional work hours whenever necessary?
If no, describe all limitations on your ability to work overtime when required in a document attached at the end of this form.
- Yes
- No
If hired, do you have a reliable means of regularly traveling to and from work?
- Yes
- No
If applicable to the position for which you are applying, what factory machines, office equipment or other devices can you operate?

Notices & Acknowledgements
Please read carefully before signing.
• Harrison Electrical, Inc. is committed to the principle of equal employment opportunity in all terms and conditions of employment, including recruitment, hiring, training, promotion, compensation, benefits, transfers, termination, company-sponsored training, education, tuition assistance and social and recreational programs. We will not discriminate against any employee or applicant for employment because of race, color, religion, sex, national origin, citizenship status, age, disability, status as a disabled veteran or veteran of the Vietnam era or any other reason prohibited by law.

• The information I have provided on this application is accurate to the best of my knowledge and subject to verification by Harrison Electric, Inc. I understand that false statements or material omissions in my application materials may result in immediate dismissal.

• I understand that if employed, I am required to abide by all rules, regulations and policies of Harrison Electrical, Inc.

• I understand that use of this application does not indicate there are any positions open and does not in any way obligate Harrison Electric, Inc. to offer me employment.

• I understand that an offer of employment is subject to my providing proof of work eligibility, as required by United States law and my completion, satisfactory to Harrison Electric, Inc., of any and all pre-employment tests and procedures Harrison Electrical, Inc. decides to use.

• I authorize Harrison Electrical, Inc. to investigate my past and present work history as well as my character, education and police records to ascertain any and all information which may be pertinent to my employment qualifications.

• I authorize the schools, employers and references I listed in my application materials to release information about my school history, work history, character and qualification to all persons, firms, agencies or companies which may request this information in connection with my application for employment with Harrison Electrical, Inc. In authorizing release of this information, I hereby release my schools, employers, references and all individuals associated with my schools, employers and references from any and all liability that may result from providing this information to Harrison Electrical, Inc. This authorization will be valid for three (3) months from the date of my signature below.

• If employed, I understand my employment and compensation can be terminated with or without cause and with or without notice at any time, at the option of either Harrison Electrical, Inc. or myself. I understand that no representative of Harrison Electrical, Inc., other than the President, has authority to enter into any agreement for employment for any specified period of time or to make any agreement contrary to provisions of this paragraph. Representations to the contrary must be in writing and must be signed by the President.

• I acknowledge that no other representations concerning the term or nature of my employment have been made to me or relied on by me.

• If employed, I agree that if Harrison Electrical, Inc. advances any paid leave before it has been accrued, advances or loans any money during the course of my employment or if I lose, damage or fail to return any property of Harrison Electrical, Inc., I authorize Harrison Electrical, Inc. to deduct from my wages sufficient funds to repay the paid leave, loans or advances or to replace its property.

• I certify I am not engaged in any outside activity or business that could be considered in conflict with the interest of Harrison Electrical, Inc. or those of its customers or clients and will not become engaged in such activity or business if employed.

• I acknowledge this application is valid for only 30 days from the date signed. I will submit a new application if I want to be considered for job openings more than 30 days from the date signed.
HARRISON ELECTRICAL, INC. IS AN EQUAL OPPORTUNITY EMPLOYER OF MINORITIES, FEMALES, INDIVIDUALS WITH DISABILITIES AND PROTECTED VETERANS
Date
Signature of Applicant
By typing your name into this form you are in agreement with the terms of this document.

Pre-Employment Consent Form
Part of the hiring process includes testing for controlled substances. If you wish to complete the application process, you must participate in such testing and consent to such testing by signing this form.
Do you consent to testing on a specimen provided by you in order to determine the presence of controlled substances and recognize that the results of an analysis of such specimen will be used to determine suitability for employment?
- Yes
- No
Applicant Signature
Date
If the applicant is under the age of 18, the testing will not be performed unless the Applicant's parent or guardian consents to the testing described above by signing this form below. Do you consent for the testing described above?
- Yes
- No
Guardian/Parent Signature
Date
By typing your name into this form you are in agreement with the terms of this document.

Voluntary Self-Identification of Disability
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. (Please reference Reasonable Accommodation Notice.) 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
• Autism

• Deafness
• Cerebral palsy

• Cancer
• HIV/AIDS
• Diabetes

• Schizophrenia

• Epilepsy

• 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 answer
Name
Date
By typing your name into this form you are in agreement with the terms of this document.
File
File
File
Please upload any additional attachments below and submit.
Please read attached E-Verify Form.*
E-Verify Form
- I have read and acknowledged the E-Verify forms.

Employment Application

.

Step 1 of 11

Personal Data

General Information

Education

Employment History

Additional Training

Military Service

Additional Information

Notices & Acknowledgements

Pre-Employment Consent Form

Equal Employment Opportunity/Affirmative Action Self-Identification Form

Voluntary Self-Identification of Disability