Page 16 - HR Solutions Catalog
P. 16

Employment Applications                                                                                                                                                                      Performance Management Forms







               California
               Application for Employment                                 Employment History (continued)
                                             Employment History
                                                                                                                                                                                                     Employee Warning Notice
              Please Print                   Starting with your most recent employer, provide the following information.   Telephone #  Explain any gaps in your employment, other than those due to personal illness, injury, or disability. _____________________________  Employee Warning Notice  Employee Warning Notice
               Equal access to programs, services and employment opportunities is available to all persons without regard to age, ancestry, color, disability,    Street address   (            )            State   ____________________________________________________________________________________________________________  Please Print
                                             Employer
               genetic information, gender, gender identity, gender expression, marital status, medical condition, military or veteran status, national origin,
               race, religion, sex (includes pregnancy, childbirth, breastfeeding, and/or related medical conditions), sexual orientation, or any other basis
                                                                          ____________________________________________________________________________________________________________
                                                                                                                                                                                                     Please Print
                                                             City
                                                                                                                                                                                                                            /         /
                                                                                                                                                                                                                            /         /
                                                                                                                                                                                                     Employee Name _________________________________________________________
               In accordance with the Americans with Disabilities Act and/or applicable state and local laws, applicants requiring reasonable accommodations   Starting job title/final job title   Dates employed     Month                Year                         Month                Year  ____________________________________________________________________________________________________________  Document employee violations and capture other important    Employee Name ____________
                                                                                                                                                                                                                        Date of Notice ____________________
                                                                  /               to                /
               protected by federal, state, and/or local law.
               for the application and/or interview process should notify the Human Resources Department. Examples of reasonable accommodations include
                                                                          If not addressed on previous page, have you ever been fired or asked to resign from a job?........................................................    Yes    No
                                                                                                                                                                                                                            /         /
                                                                                                                                                                                                                            /         /
                                                                                                                                                                                                                        Date of Hire ______________________
                                                                                                                                                                                                                        Date of Hire ______________________
                                                                                                                                                                                                     Employee/Payroll # ____________________    Department  ____________________
                                                                                                                                                                                                     Employee/Payroll # ____________________    Department  ____________________
                                                                 E-mail:
                                                             May we contact for reference?
                                             Immediate supervisor and title (for most recent position held)
               making a change to the application process; providing written materials in an alternate format such as braille, large print, or audio recording;
                                                             ■ Yes    ■ No    ■ Later
                                                                           If yes, please explain:  _______________________________________________________________________________________
               using a sign language interpreter; using specialized equipment; or modifying testing conditions.
                                             Why did you leave?
                                                                                                                                                                                                     Type of Violation
                                                                                                                                                                                                     Type of Violation
                                             Summarize the type of work performed and job responsibilities.   ________________________________________________________________________________________________________  	■	 Attendance   ■	 Willful Damage to Company Property   ■	 Other:
                                                                                                                                                                                                              ■	 Willful Damage to Company Property
                                                                                                                                                                                                     	■	 Attendance
                                                                                                                                                                                                                         ■	 Other:
               Name __________________________________________________________________ Applicant ID # _____________________  What did you like most about your position?   ________________________________________________________________________________________________________  information, including follow-up actions, employee statements      ■	 Tardy/Early Quit   ■	 Violation of Company Policies/Procedures   ■	 Other:
                                                                                                                                                                                                       ■	 Tardy/Early Quit
                                                                                                                                                                                                                         ■	 Other:
                                                                                                                                                                                                              ■	 Violation of Company Policies/Procedures
                                                                            ________________________________________________________________________________________________________
               Address __________________________________________________________________________________________________  What were the things you liked least about the position?  Telephone #  Skills and Qualifications  	■	 Inappropriate Behavior   ■	 Insubordination    ■	 Other:
                               Middle
                          First
                                                                                                                                                                                                              ■	 Insubordination
                                                                                                                                                                                                                         ■	 Other:
                                                                                                                                                                                                     	■	 Inappropriate Behavior
                   Last
                                         ZIP Code

                                     State
                                City
               Telephone # _________________ Cellular/Other Phone # ________________  E-mail Address ____________________________  Street address   (            )            State   Summarize any special training, skills, languages, licenses, and/or certificates that may assist you in performing the position for which you are applying:  and possible consequences.   	■	 Unsatisfactory Performance   ■	 Other:   ■	 Other:
                                                                                                                                                                                                              ■	 Other:
                                                                                                                                                                                                     	■	 Unsatisfactory Performance
                                                                                                                                                                                                                         ■	 Other:
                                             Employer

                    Street
                            (        )
                  (        )
                                        /         /
                                                                          ____________________________________________________________________________________________________________
                                                             City
               Position(s) applied for _____________________________________________________ Date of application __________________  Starting job title/final job title   Dates employed     Month                Year                         Month                Year  ____________________________________________________________________________________________________________  Description of Violation
                                                                                                                                                                                                     Description of Violation
               Referral Source (e.g., Walk-in, Job Posting, Company’s Website, etc.) _________________________________________________________  Immediate supervisor and title (for most recent position held)   May we contact for reference?    /               to                /  ____________________________________________________________________________________________________________  Date of Incident  __________________          Time __________________ AM AM PM PM
                                                                                                                                                                                                          /         /
                                                                                                                                                                                                          /         /
                                                                                                                                                                                                                  : :
                                                                                                                                                                                                     Date of Incident  __________________          Time __________________
                                                                 E-mail:
                                                                                                                                                                                                     Description: ________________________________________________________________________________________________
                                                             ■ Yes    ■ No    ■ Later                                                                                                                Description: ________________________________________________________________________________________________
                                             Why did you leave?           Computer Skills (Include software titles and level of experience, such as basic, intermediate, or advanced.)  ■  Provides space to note relevant specifics: date, details    __________________________________________________________________________________________________________
                                                                                                                                                                                                     __________________________________________________________________________________________________________
                           :            AM
               If necessary, best time to call you is ....................  ______________  PM  Will you relocate if job requires it? .............................   Yes    No  Summarize the type of work performed and job responsibilities.   Word Processing _________________________ Level:  _____    Internet  ________________________________Level: ______   Complies    __________________________________________________________________________________________________________
                                                                                                                                                                                                     __________________________________________________________________________________________________________
                                                                                         Other __________________________________Level: ______
                              Will you travel if job requires it? ..................................
                                          Yes  ■ No
                                                                            Spreadsheet _____________________________ Level:  _____
                  ■ Home   ■ Cellular/Other  If they have been explained to you, are you able to meet the   What did you like most about your position?   Presentation  ____________________________ Level:  _____    Other __________________________________Level: ______   of incident, actions and consequences  Employee Statement
                                                                                                                                                                                                     Employee Statement
               May we contact you at work? ....................................... ■ Yes  ■ No  What were the things you liked least about the position?   E-mail _________________________________ Level:  _____    Other __________________________________Level: ______
                                                                                                                                                                                                     ■	 I agree with employer’s statement.
                  If yes, work number and best time to call:  :            AM  PM  attendance requirements of the position? ... ■ N/A  ■ Yes  ■ No  Employer   Telephone #  with all                 ■	 I agree with employer’s statement.
                (             )
                                                                                                                                                                                                     ■	 I disagree with employer’s description of violation for these reasons:  ________________________________________________
                   ________________________________   ______________  Will you work overtime if required?  ...........................   Yes    No  (            )            Educational Background  ■	 I disagree with employer’s description of violation for these reasons:  ________________________________________________
               If you are under 18 and it is required,      If no, please explain:________________________________   Street address   City   State   Starting with your most recent school attended, provide the following information.  GPA  ■  3-part carbonless form provides copies for the employee,    __________________________________________________________________________________________________________
                                                                                                                                                                                                     __________________________________________________________________________________________________________
                                                                                        # of Years
                                                                                           Completed
                                                                                                                                                                                                     __________________________________________________________________________________________________________
               can you furnish a work permit?  ....................   N/A   ■ Yes  ■ No   ________________________________________________  Starting job title/final job title   Dates employed     Month                Year                         Month                Year  School (include City and State)  Completed    ■ Diploma      ■ GED   Class Rank  Major/Minor  federal and    __________________________________________________________________________________________________________
                                                                  /               to                /
                                                                                                                                                                                                     __________________________________________________________________________________________________________
                  If no, please explain:________________________________  Are you able to perform the “essential functions” of the job for which   Immediate supervisor and title (for most recent position held)   May we contact for reference?   E-mail:  ■ Degree ______________________    __________________________________________________________________________________________________________
                                                                                          ■ Certification __________________
               Have you submitted an application here before? ...... ■ Yes  ■ No  you are applying (with or without reasonable accommodation)?  Why did you leave?  ■ Yes    ■ No    ■ Later  ■ Other ________________________  state laws.   supervisor and recordkeeping  Actions to be Taken
                                                                                                                                                                                                     Actions to be Taken
                                                                                            ■ Diploma      ■ GED
                              do not provide information about the existence of a disability, particular accommodation,
                  If yes, give date(s) and position(s):  _____________________  This question is not designed to elicit information about an applicant's disability. Please   Summarize the type of work performed and job responsibilities.  ■ Degree ______________________    ■	Warning    ■	Probation    ■	Suspension    ■	Discharge    ■ Other:
                                                                                                                                                                                                     ■	Warning
                                                                                                                                                                                                                         ■ Other:
                                                                                                                                                                                                                    ■	Discharge
                                                                                                                                                                                                               ■	Suspension
                                                                                                                                                                                                          ■	Probation
                                                                                          ■ Certification __________________
                 ________________________________________________
                                                                                          ■ Other ________________________
                                                                                                                                                                                                     Consequence should incident occur again:  _______________________________________________________________________
                              or whether accommodation is necessary. These issues may be addressed at a later stage   What did you like most about your position?    ■ Diploma      ■ GED            Consequence should incident occur again:  _______________________________________________________________________
                                                                                          ■ Degree ______________________
               Have you ever been employed here before? ............... ■ Yes  ■ No  to the extent permitted by law.  What were the things you liked least about the position?  ■ Certification __________________    ■  Includes a ComplyRight guide to help document    __________________________________________________________________________________________________________
                                                                                                                                                                                                     __________________________________________________________________________________________________________
                                 ■ Yes     ■ No     ■  Need more information about the
                                                                                          ■ Other ________________________
                           /     /
                      /     /
                                                                                                                                                                                                     __________________________________________________________________________________________________________
                  If yes, give dates:  From ____________ To ______________     job’s “essential functions” to respond  Employer   Telephone #    ■ Diploma      ■ GED                                __________________________________________________________________________________________________________
                                                                                          ■ Degree ______________________
                Is this application a request for reemployment    Driver’s license number required if driving may be required in the   (            )            ■ Other ________________________    __________________________________________________________________________________________________________
                                                                                          ■ Certification __________________
                                                                                                                                                                                                     __________________________________________________________________________________________________________
                following an extended military leave of absence    Street address   City   State
                from this company?  ............................................... ■ Yes  ■ No   job for which you are applying:  Starting job title/final job title   Dates employed     Month                Year                         Month                Year  References  violations and manage employee infractions the right way  I have read and understand this Employee Warning Notice.
                                                                                                                                                                                                     I have read and understand this Employee Warning Notice.
                If yes, additional information may be requested.  ____________________________________  State __________  Immediate supervisor and title (for most recent position held)   May we contact for reference?    /               to                /  List names and telephone numbers of three business/work references who are not related to you and are not previous supervisors.   _________________________________________  _________________________________________  _______________
                                                                                                                                                                                                                             /      /
                                                                                                                                                                                                                             /      /
                                                                                                                                                                                                     _________________________________________
                                                                                                                                                                                                                 _________________________________________
                                                                                                                                                                                                                            _______________
                                                                          If not applicable, list three school or personal references who are not related to you.
                                                                 E-mail:
                                                                                                                                                                                                                 Signature of Employee
                                                                                                                                                                                                     Employee’s Name (Print)
                                                                                                                                                                                                                              Date
                                                                                                                                                                                                                              Date
               Are you lawfully authorized to work in    Have you ever been bonded? ....................................... ■ Yes  ■ No  ■ Yes    ■ No    ■ Later     Relationship   # of Years      _________________________________________      _________________________________________  _______________
                                                                                                                                                                                                                             /      /
                                                                                                                                                                                                     Employee’s Name (Print)
                                                                                                                                                                                                                 Signature of Employee
                                                                                                                                                                                                                            _______________
                                                                                                                                                                                                     _________________________________________
                                                                                                                                                                                                                             /      /
                                                                                                                                                                                                                 _________________________________________
               the United States? .......................................................... ■ Yes  ■ No  Have you entered into an agreement with any former employer or   Why did you leave?  Name    Title      to You  Telephone    E-mail    Known   __________________________________________________________________________________  Date Date
                                                                                                                                                                                                                 Signature of Supervisor/Manager
                                                                                                                                                                                                     Supervisor/Manager who issued warning (Print)
                                                                                                                                                                                                                 Signature of Supervisor/Manager
                                                                                                                                                                                                     Supervisor/Manager who issued warning (Print)
                                                                                                                                                                                                     __________________________________________________________________________________
                                                                                                                                                                                                     Routing
                Date available for work .........................................  ______________  other party (such as a noncompetition agreement) that might, in any   Summarize the type of work performed and job responsibilities.  (   )  A2191 – 3-Part Carbonless  Routing
                           /     /
                                                                                                                                                                                                        _______________
                                                                                                                                                                                                           ______________________________________________________________________________________
                What is your desired salary range or hourly rate of pay?  way, restrict your ability to work for our company? ...... ■ Yes  ■ No  What did you like most about your position?  (   )     _______________      ______________________________________________________________________________________
                        Per  _________________
                                                                                                                                                                                                           ______________________________________________________________________________________
                                                                                                                                                                                                        _______________
                                                                                                                                                                                                           ______________________________________________________________________________________
                                                                                                                                                                                                        _______________
                   $ _______________________       If yes, please explain: _______________________________  What were the things you liked least about the position?  (   )                             _______________   ______________________________________________________________________________________
                                                                                                                                                                                                        _______________
                                                                                                                                                                                                           ______________________________________________________________________________________
                Type of employment desired:   ■ Full-Time    Part-Time      ________________________________________________  Page 2  Page 3  A2191 – Standard Carbonless
                   ■ Educational Co-Op    Seasonal    Temporary                                                                                                                                           This product is designed to provide accurate and authoritative information. However, it is not a substitute for legal advice and does not provide legal opinions on any specific facts or services.
                                                                                                                                                                                                          This product is designed to provide accurate and authoritative information. However, it is not a substitute for legal advice and does not provide legal opinions on any specific facts or services.
                                                                                                                                                                                                          The information is provided with the understanding that any person or entity involved in creating, producing or distributing this product is not liable for any damages arising out of the use
                                                                                                                                                                                                          The information is provided with the understanding that any person or entity involved in creating, producing or distributing this product is not liable for any damages arising out of the use
                           AN EQUAL OPPORTUNITY EMPLOYER  Page 1                                                                                                                                          or inability to use this product. You are urged to consult an attorney concerning your particular situation and any specific questions or concerns you may have.
                                                                                                                                                                                                          or inability to use this product. You are urged to consult an attorney concerning your particular situation and any specific questions or concerns you may have.
                                                                                                                                      Price per pkg/50. Size: 8½" x 11".                             A2191 A2191  ©2015 ComplyRight, Inc.  Important note: This is approved for use by the purchaser only. This form may not be shared publicly or with third parties.
                                                                                                                                                                                                          Important note: This is approved for use by the purchaser only. This form may not be shared publicly or with third parties.
                                                                                                                                                                                                      ©2015 ComplyRight, Inc.
                                                                                                                                                                                                          Two easy ways to reorder: hrdirect.com • 800-999-9111
                                                                                                                                                                                                          Two easy ways to reorder: hrdirect.com • 800-999-9111
              State-Specific Application for Employment
              Gather the job-related information you need without crossing into illegal territory. These specific applications
              are available for every state and the District of Columbia, and are carefully worded to include the correct language
              and proper legal disclosures. Each state-specific application includes the proper language and legal disclosures                                                                               General Factors   Rating  Scale   Supportive Details or Comments
                                                                                                                                                                                                             7.  Creativity – The extent to which an   O   ■	  100-90   Points
                                                                                                                                                                                                              employee proposes ideas, finds new   V  ■	  89-80
              necessary to keep you in compliance with your state’s requirements.                                                                                                                  Performance Appraisal        and better ways of doing things.   G  ■	 ■	  Below 60
                                                                                                                                                                                                                         79-70
                                                                                                                                                                                                                      I

                                                                                                                                                                                                                         69-60

                                                                                                                                                                                                                      U  ■
                                                                                                                                                                                                  Please Print  8.  Initiative – The extent to which an employee   O  ■	  100-90   Points
                                                                                                                                                                                                              seeks out new assignments and assumes   V  ■	  89-80
              ■  Asks probing job-related questions including skills, employment                                                                                                                   Department _____________________________________________  Employee Payroll #__________________________________
                                                                                                                                                                                                   Employee Name __________________________________________  Title _____________________________________________
                                                                                                                                                                                                                         79-70

                                                                                                                                                                                                            additional duties when necessary.
                                                                                                                                                                                                                      G  ■

                                                                                                                                                                                                                       ■
                                                                                                                                                                                                                      I
                                                                                                                                                                                                                         69-60

                                                                                                                                                                                                                        Below 60
                                                                                                                                                                                                                      U  ■

                                                                                                                                                                                                   Reason for Review   ■	Annual     ■	Promotion   ■	Peer Appraisal   ■	Unsatisfactory Performance
                                                                                                                                                                                                           ■	End of Introductory Period
                 history and reasons for leaving, and also details gaps in history                                                                                                                   Date employee began present position _____________   Date of last appraisal ______________  O  ■	  100-90   Points /      /
                                                                                                                                                                                                       ■	Merit
                                                                                                                                                                                                           9.  Adherence to Policy – The extent to which an   ■	Other  _________________________________
                                                                                                                                                                                                                      V  ■
                                                                                                                                                                                                             /      /
                                                                                                                                                                                                                         89-80
                                                                                                                                                                                                                   /      /
                                                                                                                                                                                                            employee follows safety and conduct rules, other   Scheduled appraisal date  ____________
                                                                                                                                                                                                            regulations, and adheres to company policies.

                                                                                                                                                                                                                         79-70
                                                                                                                                                                                                                      G  ■
                                                                                                                                                                                                                      I
                                                                                                                                                                                                                         69-60
                                                                                                                                                                                                                       ■
                                                                                                                                                                                                   Instructions: Carefully evaluate employee’s work performance in relation to the essential functions of the job. Check Rating box that
                                                                                                                                                                                                                        Below 60
                                                                                                                                                                                                   indicates the employee’s performance. I  ndicate N/A if not applicable. Assign points for each Rating within the Scale and write that
                                                                                                                                                                                                                      U  ■

                                                                                                                                                                                                   number in the corresponding Points box. Points will be totaled and averaged for an overall performance score.
              ■  Includes disclosures protecting employer from liability                                                                                                                            Definitions of Performance Ratings which an employee is willing and demonstrates    O  ■	  100-90   Points
                                                                                                                                                                                                           10.  Interpersonal Relationships – The extent to

                                                                                                                                                                                                                         89-80
                                                                                                                                                                                                                      V  ■
                                                                                                                                                                                                   O – Outstanding – Performance is exceptional in all areas and   I – Improvement Needed – Performance is deficient in certain
                                                                                                                                                                                                                      G  ■

                                                                                                                                                                                                            the ability to cooperate, work and communicate
                                                                                                                                                                                                                         79-70
                                                                                                                                                                                                                 areas. Improvement is necessary.
                                                                                                                                                                                                   is recognizable as being far superior to others. with coworkers, supervisors, subordinates    I   ■	  69-60


                                                                                                                                                                                                            and/or outside contacts.  U – Unsatisfactory – Results are generally unacceptable and
                                                                                                                                                                                                                      U  ■
                                                                                                                                                                                                   V – Very Good – Results clearly exceed most position
                                                                                                                                                                                                                        Below 60
              ■  Includes a ComplyRight guide to help you screen and                                                                                                                               requirements. Performance is of high quality and is achieved    require immediate improvement. No merit increase should be
                                                                                                                                                                                                                      O  ■
                                                                                                                                                                                                   on a consistent basis.
                                                                                                                                                                                                                        100-90
                                                                                                                                                                                                           11.  Judgment – The extent to which an employee ls with this rating.
                                                                                                                                                                                                                           Points
                                                                                                                                                                                                                 granted to individua
                                                                                                                                                                                                            demonstrates proper judgment and decision-

                                                                                                                                                                                                   G – Good – Competent and dependable performance. Meets   N/A – Not Applicable or too soon to rate. 89-80
                                                                                                                                                                                                                      V  ■

                                                                                                                                                                                                            making skills when necessary.
                                                                                                                                                                                                                         79-70
                                                                                                                                                                                                                      G  ■
                                                                                                                                                                                                   the performance standards of the job.
                 interview candidates the right way                                                                                                                                                 Performance Factors               Rating  Scale   Supportive Details or Comments
                                                                                                                                                                                                                      I
                                                                                                                                                                                                                         69-60
                                                                                                                                                                                                                       ■
                                                                                                                                                                                                                        Below 60
                                                                                                                                                                                                                      U  ■
                                                                                                                                                                                                  1.  Quality – The extent to which an employee’s   O  ■	  100-90   Points  ■	Outstanding  100 - 90
                                                                                                                                                                                                           Rate employee’s overall performance in comparison to position duties and responsibilities.
                                                                                                                                                                                                     work is accurate, thorough and neat.   V  ■	  89-80  ■	Very Good  89 - 80
                                                                                                                                                                                                              Total Points   G  ■	 ■	 	÷	Number of Factors Rated  ■ ■ 	Overall Rating  ■	Good  79 - 70
                                                                                                                                                                                                                 79-70
                                                                                                                                                                                                              I
                                                                                                                                                                                                                      	=
                                                                                                                                                                                                                 69-60
                                                                                                                                                                                                                                     69 - 60
              Item No. A2179XX*                                                                                                                                                                     2.  Productivity – The extent to which an     Complete all of the following sections  ■	Improvement Needed    Below 60
                                                                                                                                                                                                              U
                                                                                                                                                                                                                Below 60
                                                                                                                                                                                                             ■ ■

                                                                                                                                                                                                                              ■	Unsatisfactory
                                                                                                                                                                                                              O  ■
                                                                                                                                                                                                                100-90
                                                                                                                                                                                                                   Points
                                                                                                                                                                                                     employee produces a significant volume   V  ■	  89-80
                                                                                                                                                                                                           1.  Accomplishments or new abilities demonstrated since last review  ____________________________________________________
              Price per pkg/50. Size: 17" x 11".                                                                                                                                                       of work efficiently in a specified period  ____________________________________________________________________________________________________________
                                                                                                                                                                                                                 79-70
                                                                                                                                                                                                              G  ■
                                                                                                                                                                                                               ■
                                                                                                                                                                                                                 69-60
                                                                                                                                                                                                   of time.
                                                                                                                                                                                                              I
                                                                                                                                                                                                              U  ■
                                                                                                                                                                                                           2.  Specific areas of needed improvement __________________________________________________________________________
                                                                                                                                                                                                                Below 60
              *Replace XX with your state abbreviation (e.g. A2179FL).                                                                                                                            3.  Job Knowledge – The extent to which   ____________________________________________________________________________________________________________
                                                                                                                                                                                                                   Points
                                                                                                                                                                                                              O  ■
                                                                                                                                                                                                                100-90
                                                                                                                                                                                                              V  ■
                                                                                                                                                                                                                 89-80

                                                                                                                                                                                                   an employee possesses the practical/technical
                                                                                                                                                                                                     knowledge required on the job.   3.  Recommendations for professional development (seminars, training, schooling, etc.)  ____________________________________
                                                                                                                                                                                                                 79-70
                                                                                                                                                                                                              G  ■
                                                                                                                                                                                                           ____________________________________________________________________________________________________________
                                                                                                                                                                                                              I
                                                                                                                                                                                                               ■
                                                                                                                                                                                                                 69-60
                                                                                                                                                                                                              U  ■
                                                                                                                                                                                                                Below 60
                                                                                                                                                                                                           4.  Absences: Number of incidents  ________________________________________   Number of days ________________________
                                                                        50-State Compliant Job Application                                                                                        4.  Reliability – The extent to which an   Employee’s Comments *   ____________________________________________________________________________________
                                                                                                                                                                                                                   Points
                                                                                                                                                                                                                100-90
                                                                                                                                                                                                              O  ■
                                                                                                                                                                                                                 89-80
                                                                                                                                                                                                              V  ■

                                                                                                                                                                                                   employee can be relied upon regarding
                                                                                                                                                                                                           ____________________________________________________________________________________________________________
                                                                                                                                                                                                           *If necessary, additional sheets may be attached. 79-70
                                                                                                                                                                                                   task completion and follow-up.

                                                                                                                                                                                                              G  ■
                                                                                                                                                                                                              I
                                                                                                                                                                                                                 69-60
                                                                                                                                                                                                               ■
                                                                                                                                                                                                              U  ■
                                                                                                                                                                                                                Below 60
                                                                                                                                                                                                              Discussed with individual on  _______________    Employee’s Signature *  _____________________________________________
                                                                                                                                                                                                                  /       /
                                                                                                                                                                                                                           *I acknowledge that this Performance Appraisal was discussed with me.
                                                                                                                                                                                                  5.  Attendance – The extent to which an  Follow-up requested/desired ■	Yes  ■	No   Follow-Up Date  _________________
                                                                                                                                                                                                                100-90
                                                                                                                                                                                                                   Points
                                                                                                                                                                                                                                   /       /
                                                                                                                                                                                                              O  ■
           Application for Employment                                                                                                                                                                employee is punctual, observes prescribed    V  ■	  89-80  Date  _________________
                                                                                                                                                                                                                                   /       /
                                                                                                                                                                                                           Evaluator’s Signature ________________________________________________________________
                                                                                                                                                                                                              I
                                                                                                                                                                                                   acceptable overall attendance record.
                                                                                                                                                                                                                 69-60
           Please Print  Employment History  Employment History         For businesses that operate in more than one state, these                                           Save time                  work break/meal periods, and has an    G  ■	 ■	  79-70
                                                                                                                                                                                                                Below 60
                 Starting with your most recent employer, provide the following information. You may include any verified work performed on a volunteer basis.  Starting with your most recent employer, provide the following information. You may include any verified work performed on a volunteer basis.         U  ■	 This product is designed to provide accurate and authoritative information. However, it is not a substitute for legal advice and does not provide legal opinions on any spec
                                                                                                                                                                                                               The information is provided with the understanding that any person or entity involved in creating, producing or distributing this product is not liable for any damages arising out of the use
                 Employer       Telephone #  Employer      Telephone #                                                                                                                                         or inability to use this product. You are urged to consult an attorney concerning your particular situation and any specific questions or concerns you may have.
                                                                                                                                                                                                                   Points
                                                                                                                                                                                                          ©2016 ComplyRight, Inc. O  ■
                                                                                                                                                                                                                100-90
                                (            )
           Equal access to programs, services and employment opportunities is available to all persons without regard to sex (including pregnancy),  State   Street address   (            )                     State   applications capture job-related information you need.    with duplicate   6.  Independence – The extent to which an    Important note: This is approved for use by the purchaser only. This form may not be shared publicly or with third parties.
                                                                                                                                                                                                               Two easy ways to reorder: hrdirect.com • 800-999-9111
                                                           City
                                City
                                                                                                                                                                                                          A2192
                 Street address
           race, color, religion, national origin, citizenship, age, disability, genetic information, or any other basis protected by federal, state,                                                employee performs work with little or    V  ■	  89-80
           and/or local law.   Starting job title/final job title   Dates employed     Month                Year                         Month                Year  Starting job title/final job title   Dates employed     Month                Year                         Month                Year  warning slips.       no supervision.   G  ■	 ■	  79-70
                                                                                                                                                                                                              I

                                     /               to                /
                                                                /               to                /
                                                                                                                                                                                                                 69-60
           In accordance with the Americans with Disabilities Act and/or applicable state and local laws, applicants requiring reasonable  E-mail:  Immediate supervisor and title (for most recent position held)   May we contact for reference?   E-mail:  Bestseller         U  ■	  Below 60
                 Immediate supervisor and title (for most recent position held)
                                May we contact for reference?
           accommodations for the application and/or interview process should notify the Human Resources Department. Examples of reasonable   ■ Yes    ■ No    ■ Later  They’re attorney developed and carefully worded to include
                                ■ Yes    ■ No    ■ Later
           accommodations include making a change to the application process; providing written materials in an alternate format such as braille,   Why did you leave?
                 Why did you leave?
           large print or audio recording; using a sign language interpreter; using specialized equipment; or modifying testing conditions.
                 Summarize the type of work performed and job responsibilities.  Summarize the type of work performed and job responsibilities.
                 What did you like most about your position?  What did you like most about your position?  the correct language and proper legal disclosures required
           Name __________________________________________________________________ Applicant ID # _____________________  What were the things you liked least about the position?
                 What were the things you liked least about the position?
                Last   First   Middle
                                Telephone #
                 Employer
           Address __________________________________________________________________________________________________  Employer   Telephone #  Consecutive Employee Warning Report              Performance Appraisal
                                 State
                Street     City   (            )                     ZIP Code  (            )
                                                                State
              (        )
           Telephone # _________________  (        )  City   State   Street address   City  Dates employed     Month                Year                         Month                Year  by all federal and state laws.  
                 Street address  Cellular/Other Phone # ________________  E-mail Address ____________________________
                                  /         /
                 Starting job title/final job title
                                     /               to                /
                                  Month                Year                         Month                Year
           Position(s) applied for _____________________________________________________ Date of application __________________  Starting job title/final job title     /               to                /
                                Dates employed
                                            Immediate supervisor and title (for most recent position held)   May we contact for reference?   E-mail:
                 Immediate supervisor and title (for most recent position held)   May we contact for reference?   E-mail:
           Referral Source (e.g., Walk-in, Job Posting, Company’s Website, etc.) _________________________________________________________  ■ Yes    ■ No    ■ Later
                                ■ Yes    ■ No    ■ Later
                 Why did you leave?         Why did you leave?
                      :            AM  Will you travel if job requires it? ..................................■ Yes  ■ No  Summarize the type of work performed and job responsibilities.  ■  Excludes criminal questions in compliance    Document all employee infractions, especially those with multiple   Simplify the performance review process and provide
           If necessary, best time to call you is ....................  ______________  PM
                 Summarize the type of work performed and job responsibilities.
              ■ Home   ■ Cellular/Other What did you like most about your position?  If they have been explained to you, are you able to meet the    What did you like most about your position?
           May we contact you at work? ....................................... ■ Yes  ■ No  attendance requirements of the position? ... ■ N/A  ■ Yes  ■ No  What were the things you liked least about the position?
                 What were the things you liked least about the position?
              If yes, work number and best time to call:  Will you work overtime if required? ...........................   Yes    No  with “ban the box” laws  occurrences. Distribute written warning slips for up to three   employees a clear way to measure their progress.
                      :            AM
                 Employer
               ________________________________   ______________  PM       If no, please explain:  _______________________________  Employer   Telephone #
            (             )
                                Telephone #
                                (            )
                                                           (            )
                           ________________________________________________
                 Street address
           If you are under 18 and it is required,   City   State   Street address   City   State
           can you furnish a work permit? .................... ■ N/A  ■ Yes  ■ No  Are you able to perform the “essential functions” of the job for which   Starting job title/final job title   Dates employed     Month                Year                         Month                Year  infractions and record the dates and reasons for each warning.
                 Starting job title/final job title   you are applying (with or without reasonable accommodation)?     /               to                /
                                Dates employed
                                  Month                Year                         Month                Year
                                     /               to                /
              If no, please explain:  _______________________________  This question is not designed to elicit information about an applicant's disability.   Immediate supervisor and title (for most recent position held)   May we contact for reference?   E-mail:  ■  Excludes salary history questions in compliance
                                May we contact for reference?
                                    E-mail:
                 Immediate supervisor and title (for most recent position held)   Please do not provide information about the existence of a disability, particular                             ■  Uses a simple 100-point rating scale with comment
           Have you submitted an application here before? ...... ■ Yes  ■ No  accommodation or whether accommodation is necessary. These issues may be   Why did you leave?  ■ Yes    ■ No    ■ Later
                                ■ Yes    ■ No    ■ Later
                 Why did you leave?  addressed at a later stage to the extent permitted by law.
              If yes, give date(s) and position(s):  ____________________  Summarize the type of work performed and job responsibilities.
                 Summarize the type of work performed and job responsibilities.   Yes    No    Need more information about the  with the “salary history ban” and equal pay laws
               ________________________________________________         job’s “essential functions” to respond  What did you like most about your position?  ■  Capture necessary documentation on repeat    areas to explain the ratings
           Have you ever been employed here before? ............... ■ Yes  ■ No  Driver’s license number required if driving may be required in the   What were the things you liked least about the position?
                 What did you like most about your position?
                  /     /
                      /     /
              If yes, give dates:  From ____________ To ______________  job for which you are applying:
                 What were the things you liked least about the position?
                         ____________________________________  State __________  Employer   Telephone #
           Is this application a request for reemployment following an extended   Telephone #  (            )                           offenders and actions taken
                 Employer
                                (            )
           military leave of absence from this company? ........... ■ Yes  ■ No  Have you ever been bonded? .......................................   Yes    No  Street address   City   State   ■  Includes a ComplyRight guide to help you screen
                 Street address   City   State                                                                                                                                                  ■   Includes a ComplyRight guide to help correctly
              If yes, additional information may be requested.  Have you entered into an agreement with any former employer or   Starting job title/final job title   Dates employed     Month                Year                         Month                Year
                                  Month                Year                         Month                Year
                                Dates employed
                 Starting job title/final job title
                                     /               to                /
            Contains
           Are you lawfully authorized to work    other party (such as a noncompetition agreement) that might, in any   Immediate supervisor and title (for most recent position held)   May we contact for reference?    /               to                /
                                    E-mail:  Yes    No
                                                               E-mail:
                         way, restrict your ability to work for our company? ........
           in the United States? ...................................................... ■ Yes  ■ No     If yes, please explain: _______________________________  Why did you leave?  ■ Yes    ■ No    ■ Later  and interview candidates the right way   ■  Includes a ComplyRight guide to help document    conduct effective employee evaluations
                                May we contact for reference?
                 Immediate supervisor and title (for most recent position held)
                                ■ Yes    ■ No    ■ Later
                      /     /
                 Why did you leave?
           Date available for work .........................................  ______________      ________________________________________________
             mandatory   NOTE TO RHODE ISLAND APPLICANTS: This company is subject to the state’s workers’ compensation   What did you like most about your position?
           What is your desired salary range or hourly rate of pay?      ________________________________________________  Summarize the type of work performed and job responsibilities.
                 Summarize the type of work performed and job responsibilities.
                   Per  _________________
            $ _______________________
                 What did you like most about your position?
                  ■ Full-Time
                     ■ Part-Time
           Type of employment desired:   What were the things you liked least about the position?  laws (Chapter 29-38) unless otherwise noted below (employer to list applicable exemptions):  What were the things you liked least about the position?  A0019 – Long Form    and discipline employees the right way  Item No. A2192
                         ____________________________________________________
          disclosures for  ■ Temporary  ____________________________________________________  Page 2  Page 2
                  ■ Seasonal
            ■ Educational Co-Op

                         ____________________________________________________
           Will you relocate if job requires it?
                      ■ Yes  ■ No
           all 50 states.  AN EQUAL OPPORTUNITY EMPLOYER  Page 1  Long Form; 4 pages   A0374 – Short Form                             Item No. A2187                                            Price per pkg/50. Standard: 8½" x 11".
                                                                        Price per pkg/50. Long form: 17" x 11". Short form: 8½" x 11".   Price per pkg/50. 4-Part carbonless. Size: 8½" x 11".
        16                                   Employee Management Forms                                                                                                 Employee Management Forms                                           17
   11   12   13   14   15   16   17   18   19   20   21