Employment Application 952-949-3700 9675 West 76th Street, Suite 200 Eden Prairie, MN 55344 www.avisystems.com
Applicant Information Date: Last First M.I. Street Address Apt/Unit # City State ZIP Code Email: Date Available: Desired Salary: Position Applied For: How did you learn about this position? Are you a citizen of the United States? If no, are you authorized to work in the US? Have you ever worked for this company? If so, when? Education High School: College: Did you graduate? Degree: Degree: Degree: Other: Did you graduate? Did you graduate? Training Describe any specialized training, skills and extracurricular activities below. Page 2 of 6
References Relationship: Relationship: Relationship: Previous Employment - list current/most recent employment first Supervisor: Job Title: Starting Salary: Ending Salary: Responsibilities: From (Month/Year): To (Month/Year): May we contact your previous supervisor for a reference? Comment: Reason for Leaving: Supervisor: Job Title: Starting Salary: Ending Salary: Responsibilities: From (Month/Year): To (Month/Year): May we contact your previous supervisor for a reference? Comment: Reason for Leaving: Supervisor: Job Title: Starting Salary: Ending Salary: Responsibilities: From (Month/Year): To (Month/Year): May we contact your previous supervisor for a reference? Comment: Reason for Leaving: Page 3 of 6
Military Service Branch: Rank at Discharge: Type of Discharge: If other than honorable, explain: Disclaimer and Signature I certify that my answers are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge 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 such change is specifically acknowledged in writing by an authorized Executive of this organization. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. I understand, also, that I am required to abide by all rules and regulations of the employer. Signature: Date: Page 4 of 6
Equal Opportunity Employer/Minorities/Females/Vet/Disabled Survey AVI Systems is an EOE/M/F/Vet/Disabled and does not discriminate in hiring or employment on the basis of race, creed, color, age, religion, sex, gender, national origin, disability, genetic information, veteran status, marital status, sexual or affectional orientation, military service, or any other basis prohibited by federal, state or local laws. To help us accurately comply with Federal EOE/M/F/Vet/Disabled reporting requirements, we request your assistance and cooperation in supplying the following information. Submission of this information is voluntary. This information will be treated confidential and will not be used in any manner that could adversely affect any hiring decision, your employment, compensation, promotion, transfer opportunity or any other condition of employment. We also invite you to tell us (Human Resources) now, or at any time in the future, about any reasonable accommodations that you believe AVI Systems could make which would better enable you to perform the essential functions of the job properly and safely which includes the application process. POSITION APPLYING FOR: Please Check One: Male Female MINORITY AND ETHNIC IDENTIFICATION: (CHECK ALL APPROPRIATE RACE/ETHNIC GROUPS) Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, Central or South 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 rth 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 Pacific Islander (not Hispanic or Latino) - A person having origins in any of the peoples Hawaii, Guam, Samoa, or other Pacific Island. Asian (not Hispanic or Latino) - A personal 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 Alaskan Native (not Hispanic or Latino) - A person having origins in any of the original peoples of rth and South America (including Central America), and who maintains 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. CONTINUED ON THE NEXT PAGE Page 5 of 6
Equal Opportunity Employer/Minorities/Females/Vet/Disabled Survey VETERAN STATUS Special Disabled Veteran - means (A) a veteran 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 Veteran's Affairs for a disability (i) rated at 30 percent or more, or (ii) rates at 10 or 20 percent in the case of a veteran who has been determined under Section 3106 of Title 38, U.S.C to have a serious employment handicap or (B) a person who was discharged or released from active duty because of a service-connected disability. Veteran of the Vietnam Era - means a person who: (A) served in the military, ground, naval or air service of the United States on active duty for a period of more than 180 days, and was discharged, if any part of such active duty occurred: (i) in the Republic of Vietnam between February 28, 1961 and May 7, 1975; or (ii) between August 5, 1964 and May 7, 1975 or (B) was discharged or released from active duty for a service-connected disability if any part of such active duty was performed (i) in the Republic of Vietnam between February 28m 1961 and May 7, 1975; or (ii) between August 5, 1964 and May 7, 1975, in all other cases. Other Eligible Veterans - means veterans who served in the military, ground, naval or air service of the United States on active duty during a war or in a campaign or expedition for which a campaign badge has been authorized. To identify the campaigns or expeditions that meet this criterion, contact the Office of Personnel Management (OPM) and ask for the OPM VETS Guide, Appendix A. A local OPM telephone number may be found in the telephone book under Federal Government or consult Directory Assistance for your area code for the nearest OPM location. For those with internet access, the information required to make this determination also is available at: http://www.opm.gov/veterans/html/vgmedal2.asp. Newly Seperated Veteran - Veteran who served on active duty and was discharged or released within the last three years. Veteran - Individuals, who served in the military, ground, naval or air service of the United States on active, guard and/or reserves duty that the three categories above do not apply to. t Applicable - Does not Apply OTHER STATUS Individual With Disabilities - Any person who has a physical or mental impairment which substantially limits one or more of his/her major life activity(s), or has a record of such impairment(s), or is regarded as having such impairment(s). If you checked Disabled or Special Disabled Veteran, you may identify any reasonable accommodations AVI Systems could consider and/or offer that would better enable you to complete the application process or perform the essential functions of the job properly and safely, if selected: Print Employee Name: Signature: Page 6 of 6 Date: