Ancos Employment Application, Disputanta VA

Your Information
Name*
First Last
Current Address*
Street Address Address Line 2 City State ZIP Code
Years at Current Address*
Email*
Phone*
Alternate Phone
Date of Birth*
MM slash DD slash YYYY

Position and Availability
Desired Position*
Alternate Position
Desired Hourly Rate / Salary
Desired Hours Per Week
Available to Work Nights?
- Yes
- No
Employment Type Desired
- Full Time
- Part Time
- Part or Full Time
Desired Start Date
MM slash DD slash YYYY
Referral

Education

School Name	School Location	Years Completed	Major / Degree / Certificate

Background
Have you ever been convicted of a felony?*
- Yes
- No
If yes, please explain.
Do you have a valid VA driver's license?
Driver’s License Number
State of Issue
Type of License
- Operator
- Commercial (CDL)
- Chauffeur
Class of CDL
- A
- B
- C
- D
Endorsement and Restrictions
- T
- P
- N
- H
- X
- S
Other Endorsements or Restrictions
Expiration Date
MM slash DD slash YYYY
Have you had any accidents during the past three years?
- Yes
- No
How many?
Have you had any moving violations during the past three years?
- Yes
- No
How many?
Do you have a valid forklift driver's license?
- Yes
- No
Do you have forklift driving experience?
- Yes
- No
Years of Forklift Experience
Have you ever been in the Armed Forces?
- Yes
- No
Are you now a member of the National Guard or Reserves?
- Yes
- No

Specialty	Date Entered	Date Discharged

Medical
Are you on any medications?
- Yes
- No
Are you under ongoing doctor's care?
- Yes
- No
If yes to either, please explain.
Do you have any physical defects that preclude you from performing any work for which you are being considered?
- Yes
- No
If yes, please explain.
Can you lift up to 75 lbs?
- Yes
- No
Have you ever been seriously injured?
- Yes
- No
If yes, please explain.
Do you have any defects with the following?
- Hearing
- Vision
- Speech
Emergency Contact
Name Address Phone Number

References
Please list two references other than relatives or employers.
Reference #1
Name Address Phone Email
Reference #2
Name Address Phone Email

Work History
Please enter information for your last TEN years of employment.
Employer #1
Employer Name Phone City, State
Job Title Supervisor Dates Employed Salary
Reason for Leaving
List jobs held, duties performed, skills used or learned, advancements or promotions.
Employer #2
Employer Name Phone City, State
Job Title Supervisor Dates Employed Salary
Reason for Leaving
List jobs held, duties performed, skills used or learned, advancements or promotions.
Employer #3
Employer Name Phone City, State
Job Title Supervisor Dates Employed Salary
Reason for Leaving
List jobs held, duties performed, skills used or learned, advancements or promotions.
May we contact your present employer?
- Yes
- No

File Uploads
Resume Upload
Accepted file types: pdf, doc, docx, Max. file size: 512 MB.
Cover Letter Upload
Accepted file types: pdf, doc, docx, Max. file size: 512 MB.

Agreement and Submit
Did you complete this application yourself?*
- Yes
- No
If no, who completed this application?
I certify that all the information on this application is accurate and complete to the best of my knowledge and understand that misleading or false statements will constitute sufficient cause for refusal of hire or termination of my employment. I understand that neither the acceptance of this application nor the subsequent entry into any type of employment relationship with Ancos, Inc creates an actual or implied contract of employment. I understand that, if I accept employment with Ancos, Inc, it will be on an at-will basis. This means that either Ancos, Inc or I have the right to terminate the employment relationship at any time, for any reason, with or without cause. I agree to submit to drug and alcohol testing, if requested by Ancos, Inc and I release Ancos, Inc, and its employees, plus other persons or companies, from any and all liability arising out of or related in any way to such testing. I authorize Ancos, Inc to investigate information concerning my education, employment experiences and all other aspects of my background relevant to my proposed employment. I release Ancos, Inc and its employees from all liability arising from such investigation. Ancos, Inc is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with Ancos, Inc depends solely on your qualifications.
Confirmation*
- I agree with the above statement

Employment Application

Step 1 of 9

Your Information

Position and Availability

Education

Background

Medical

References

Work History

File Uploads

Agreement and Submit

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