LGS MANAGEMENT INC.

Employment Application

An Equal Opportunity Employer

Drug Free Workplace

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Dear Applicant,

Thank you for applying to LGS Management Inc. Each question on this application should be fully and accurately answered. No action can be taken until all questions have been answered. Use blank paper if you need additional space. PLEASE PRINT, except for your signature. Modified applications are not acceptable. In reading and answering the following questions, be aware that none of the questions are intended to imply illegal preferences or discrimination based upon non-job-related information. Include any job-related military service assignments and volunteer activities. You may exclude organizations, which indicate race, color, religion, gender, national origin, disabilities or other protected status.

Last Name: First Name: MI:
Address: City: State: Zip:
Phone No.: Alternate No.:
E-mail:  
Today’s Date: Available Start date:
Job Applying For: Job Announcement No.:
Are You Seeking: Full-time Part-time On-call Temporary
How did you hear about this position?
Have you ever filed an application with LGS before?  - Yes - No
Have you ever been employed by LGS? - Yes - No
- If yes, list date range, position and location:
Is any member of your family currently employed by LGS? - Yes - No
- If yes, please identify name and relationship:
May we contact your present employer? - Yes - No
Are you prevented from lawfully becoming employed in the U.S. because of visa or immigration status? (Proof of citizenship or immigration status required upon employment.) - Yes - No
Are you currently on “lay-off” status and subject to recall? - Yes - No
   
Have you ever worked or attended school under any other name? - Yes - No
- If yes, list names
Have you ever been fired from a job or asked to resign? - Yes - No
- If yes, please explain.
Have you ever been convicted of a criminal offense (felony or misdemeanor)? - Yes - No
- If yes, please describe the crime - state nature of the crime(s), when and where convicted and disposition of the case.
(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)
May we contact your present employer? - Yes - No

Work History

List names of employers in consecutive order with present or last employer listed first.  Account for all periods of time including military services and any periods of unemployment.  If self-employed, give firm name and supply business references. Do not substitute your resume for employment history.


Employer I: Supervisor: Supervisor Phone No.:
Address: City: State: Zip:
Employed: From (MM-YYYY): To (MM-YYYY):
Pay: Start: Final:
Title:
Reason Left :
Primary Duties:
May we contact this employer? - Yes - No  
     
Employer II: Supervisor: Supervisor Phone No.:
Address: City: State Zip:
Employed: From (MM-YYYY): To (MM-YYYY)
Pay: Start: Final:
Title:
Reason Left :
Primary Duties:
May we contact this employer? - Yes - No  
     
Employer III: Supervisor: Supervisor Phone No.:
Address: City: State: Zip:
Employed: From (MM-YYYY): To (MM-YYYY):
Pay: Start: Final:
Title:
Reason Left :
Primary Duties:
May we contact this employer? - Yes - No  
     

Education

High School or GED

Name:
Address:
Years Completed: Diploma/Degree/Certificate:
       
College or University
Name:
Address:
Years Completed: Diploma/Degree/Certificate:
       
       
Vocational or Technical
Name:
Address:
Years Completed: Diploma/Degree/Certificate:
       
       

Professional Licenses, Registrations and Certifications

Type of License Name on License License No. Exp Date State
List professional, trade, business or civic activities, and offices held.  You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or protected status.
 
Describe any specialized training apprenticeship, skills, and extra-curricular activities.
 
Describe any job-related training received in the United States Military.
 

References

Provide the name of three persons, not related to you, whom you have known at least one year.

Name E-mail Phone Business or Personal Years Known

Attachment A

(Application not valid unless signed.)

I certify that answers given herein 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 60 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 an authorized executive of this organization specifically acknowledges such change in writing.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge.  I understand, also, that I am required to abide by all rules and regulations of the employer.

I agree to have a drug screening analysis for substance abuse and understand that any offer of employment is contingent upon my passing this drug screening.

I HAVE READ, UNDERSTAND, AND BY MY SIGNATURE AGREE AND CONSENT TO THESE STATEMENTS.

Signature Date

Attachment B

Prior Employment Consent
Applicant Name:
       
1 Previous Employer (most recent):
Previous Employer’s Address:
Phone Number: Alt. Phone Number:
Dates of Employment From: To:
Job Title:
Reason for Leaving:
2 Previous Employer:
Previous Employer’s Address:
Phone Number: Alt. Phone Number:
Dates of Employment From: To:
Job Title:
Reason for Leaving:
3 Previous Employer:
Previous Employer’s Address:
Phone Number: Alt. Phone Number:
Dates of Employment From: To:
Job Title:
Reason for Leaving:
I consent to and authorize LGS Management Inc., to make a full and complete investigation of my personal or employment history and authorize any former employer, person, firm, corporation, school, credit agency, or other entity to provide LGS Management, Inc with any information of any sort (including fact or opinion) they may have regarding me.  In consideration of LGS’s review of this application, I release LGS Management, Inc and all providers of any information from any liability as a result of furnishing and receiving this information.
Signature Date

Attachment C

Applicant’s Informed Consent to Drug and Alcohol Testing
Please read this document carefully.

The Company is committed to providing a safe and healthy environment for all employees, customers and the public.  It is also committed to eliminating the hazards in the workplace created by drug abuse and has adopted a drug-free workplace policy.  Accordingly, all job offers will be contingent upon a new hire passing a drug and alcoholtest prior to employment.  The Company will not hire anyone who fails this test.

  1. I, , understand that if I receive a conditional offer of employment, I will be required to do a drug and alcohol test, and must report to the designated collection site within twenty-four (24) hours of the offer.  Because of administrative complexities, however, international hires may be given additional time to complete the testing.

  2. I understand that this policy provides for drug and alcohol testing.  Unless I am advised otherwise in advance and in writing by the Company, substance abuse testing at the Company will test for the following substances: marijuana, cocaine, opiates, amphetamines (including crystal methamphetamine), phencyclidine (PCP) and alcohol.

  3. By this acknowledgment, I am advised that over-the-counter medications or prescribed drugs may result in a positive test result for drug testing.  I understand that it is my responsibility to notify the Medical Review Officer if I have taken any over-the-counter medication or prescribed drugs within the past thirty (30) days.

  4. I understand that if I refuse to be tested, fail to report within the required time, leave the designated collection site without providing a urine specimen, refuse to sign a release and authorization to submit to any drug screen test, refuse to sign the consent form to permit the Medical Review Officer to provide the results to the Company, and/or fail the test, I will not be eligible for hire at the Company.

  5. I freely and voluntarily consent to submit to alcohol and drug testing as requested by the Company.  I understand that the test results will be reported to the Company’s Designated Employer Representative by the Medical Review Officer, including the identification of the controlled substance(s) for positive results. 

  6. I understand and agree to the release of the pre-employment test results of any substance abuse test administered by the medical testing laboratory to the Medical Review Officer and the Company’s Designated Employer Representative.  I understand the purpose of the disclosure is to determine if I have violated the Company’s Drug and Alcohol Policy.

  7. I understand that information regarding my test results is confidential and cannot be disclosed without my written consent, unless otherwise required by law.  I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically upon my rejection for employment with the Company.
Applicant Name (Print) Applicant Signature Date

CONFIDENTIAL VOLUNTARY QUESTIONNAIRE

As an equal opportunity employer and government contractor, we are obligated by Federal regulations to monitor our employment practices to ensure nondiscrimination, measure the effectiveness of our affirmative action program and produce required reports. To assist in this process, you are invited to complete this questionnaire which will be greatly appreciated.

You are NOT required by law to provide the information requested. If you elect to provide the data, it will be detached from your application, be kept confidential, and used only in accordance with government regulations and Affirmative Action Policy. Refusal to provide this data will not adversely affect consideration for employment.

Race/Ethnic Group: Hispanic or Latino  
  White (not Hispanic or Latino)
  Black or African American (not Hispanic or Latino)
  Asian (not Hispanic or Latino)
  Native Hawaiian or Other Pacific Islander (not Hispanic or Latino)
  American Indian or Alaskan Native (not Hispanic or Latino)
  Two or more races (not Hispanic or Latino)
Sex: Male Female

VETERANS STATUS

1. Served on active duty during any war, campaign, or expedition for which a campaign badge was authorized? - Yes - No

2. Received an Armed Forces service medal? - Yes - No

3. Recently separated veteran (discharged or released from active duty within 3 year)?  - Yes - No

4. Disabled veteran? - Yes - No

Position you are applying for: Date:

How were you referred to this office? Advertisement  Relative/Friend  Employment Agency Walk-in
Other please describe:

Applicant Name (Print) Applicant Signature Date