Note: Use the TAB key to navigate between fields.

Date: E-mail:
Last Name: First Name: M.I. SSN: 
Street Address: Home Phone:  
City, State, Zip: Cell Phone:  

Have you ever been employed with us?  Yes   No
    If yes, month and year and location
   
Position Desired: Shift Desired: Desired Rate of Pay:
After reviewing the job description(s), can you perform the functions of the job(s) for which you are applying?  Yes   No
    If no, could you do so with reasonable accommodation? Yes   No
    If yes, describe type of accommodations needed:
   
If applying for a Nursing Assistant position, are you certified? Yes   No
   
Apart from absence for religious observance, are you available for full-time work? Yes   No
    If not, what hours can you work?
    Will you work overtime if necessary? Yes   No
    When will you be available to begin work?
   
Are you legally eligible for employment in the United States? Yes   No
How did you learn of an opening? 
   
If you are under 18 years of age, can you provide required proof of you eligibility to work?Yes   No

<
Level of
Education
Name and Location of School
Course of Study
# of Years
Completed
Did You
Graduate?
Graduate
Yes   No
College
Yes   No
Business/Trade
School
Yes   No
High School
Yes   No
Elementary
Yes   No

EMPLOYMENT
Please give accurate, complete full-time and part-time employment record.
Start with your present or most recent employer.


(1) Company Name:  Telephone: 
City/State:  Employed  (State month, year)
From:    To: 
Name of Supervisor:  Rate of Pay
Start:   Last: 
Job Title and Describe Your Work:  Reason for Leaving: 
  O.K. to Contact Employer:  Yes   No


(2) Company Name:  Telephone: 
City/State:  Employed  (State month, year)
From:    To: 
Name of Supervisor:  Rate of Pay
Start:   Last: 
Job Title and Describe Your Work:  Reason for Leaving: 
  O.K. to Contact Employer:  Yes   No


(3) Company Name:  Telephone: 
City/State:  Employed  (State month, year)
From:    To: 
Name of Supervisor:  Rate of Pay
Start:   Last: 
Job Title and Describe Your Work:  Reason for Leaving: 
  O.K. to Contact Employer:  Yes   No


(4) Company Name:  Telephone: 
City/State:  Employed  (State month, year)
From:    To: 
Name of Supervisor:  Rate of Pay
Start:   Last: 
Job Title and Describe Your Work:  Reason for Leaving: 
  O.K. to Contact Employer:  Yes   No

CO-WORKER REFERENCES
(No relatives)

Name
City/State
Phone
Years Acquainted
1. 
2. 
3. 

Winning Wheels, Inc. does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, or on the basis of age or mental or physical disability, including pregnancy, unrelated to the ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination.

I voluntarily give Winning Wheels, Inc. the right to make a thorough investigation of my past employment and activities, including criminal, and I agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information. If hired, I consent to a physical examination and understand that my employment offer will be contingent on passing the physical examination, and such future physical examination as may be required by Winning Wheels, Inc. in accordance with its policies and with the regulatory agency.

I understand that I must successfully pass an initial drug screen to be employed with this organization.

I understand that my employment is at will, and that either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misrepresentation or omission of fact appearing on this application.

If employed, I will be required to complete an Employment Verification Form (I-9) and within three days show satisfactory evidence of identity and eligibility for employment.

Winning Wheels Application for Employment
Non-Discrimination and Compliance Disclosure

Winning Wheels is an equal opportunity provider and employer.

If you wish to file a Civil Rights complaint if discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250- 9410, by fax (202) 690-7442 or email at program.intake@usda.gov.


The following information is requested by the Federal Government in order to monitor compliance with Federal Laws prohibiting discrimination against applicants seeking to participate in this program. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note the race/national origin of individual applicants on the basis of visual observation or surname.

I do not wish to furnish this information

Ethnicity:   Race:  
 

 


Gender: