Apply for Safety Manager - Cleveland Group, Inc.

Please fill out the form below and click Submit to submit your application for consideration. Fields with an asterisk (*) are required.

Summary
Title:	Safety Manager
ID:	0924
Department:	Operations
Contact Information
* First Name:
* Last Name:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Phone:
* Email:
Attachments
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Cover Letter:	You can type in a Cover Letter or Copy/Paste from an existing document.

Application for Employment – Short Version

PERSONAL INFORMATION

* Are you legally eligible to be employed in the United States? (Proof of identity and eligibility will be required upon employment):

Yes No

* Are you at least 18 years or older? (If no, you may be required to provide authorization to work):

Yes No

* Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation?:

Yes No

If no, please explain:

EMPLOYMENT DESIRED

* When would you be available to begin work?:

* Hourly rate/salary desired:

* Are you currently employed?:

Yes No

If so may we inquire of your present employer?:

Yes No

If presently employed, why are you considering leaving?:

EDUCATION

Give record of all High Schools, Colleges, Universities and Vocational/Technical Schools you have attended.

School Name & Location	Did you Graduate?	Degree Received	Subjects Studied/Major
	Yes No
	Yes No
	Yes No

Please list any special courses, seminars and/or training, computer skills or other relevant skills that would help you to perform the position for which you are applying, please describe:

EMPLOYMENT HISTORY

Give your full employment record, starting with your current or most recent employment

EMPLOYER 1

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Job Title	Supervisor Name & Title	May we Contact?
		Yes No
Responsibilities	Reason for Leaving	Salary/Hourly Rate
		Start: End:

EMPLOYER 2

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Job Title	Supervisor Name & Title	May we Contact?
		Yes No
Responsibilities	Reason for Leaving	Salary/Hourly Rate
		Start: End:

EMPLOYER 3

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Job Title	Supervisor Name & Title	May we Contact?
		Yes No
Responsibilities	Reason for Leaving	Salary/Hourly Rate
		Start: End:

AUTHORIZATION

The facts set forth in this application and any supplemental information are true and complete to the best of my knowledge. I understand that, if employed, falsified statements on this application shall be considered sufficient cause for immediate discharge. I hereby authorize investigation of all statements contained herein and employers listed above to give you any and all information concerning my employment, and any pertinent information they may have, and release all parties from all liability for any damage that may result from furnishing same.

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for the company to hire me.

I understand that I am required to abide by all rules and regulations of the company.

* Signature (type name):

* Date:

Veteran Pre-Offer Self-Identification

Invitation to Self-Identify

VETERANS

First State Bank is a Government contractor subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications are defined as follows:

A "disabled veteran" is one of the following:
- A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or
- A person who was discharged or released from active duty because of a service-connected disability.
A "recently separated veteran" means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.
An "active duty wartime or campaign badge veteran" means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.
An "Armed forces service medal veteran" means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

Protected veterans may have additional rights under USERRA—the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor's Veterans Employment and Training Service (VETS), toll-free, at 1-866-4-USA-DOL.

If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below. As a Government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.

I identify as one or more of the classifications of Protected Veteran listed above.
I am not a Protected Veteran

Voluntary Self-Identification of Disability CC-305

Voluntary Self-Identification of Disability

Form CC-305
OMB Control Number 1250-0005
Expires 01/31/2017

Why are you being asked to complete this form?

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities.ⁱ To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

How do I know if I have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

Disabilities include, but are not limited to:

Blindness
Deafness
Cancer
Diabetes
Epilepsy

Autism
Cerebal palsy
HIV/AIDS
Schizophrenia
Muscular dystrophy

Bipolar disorder
Major depression
Multiple sclerosis (MS)
Missing limbs or partially missing limbs

Post-traumatic stress disorder (PTSD)
Obsessive compulsive disorder
Impairments requiring the use of a wheelchair
Intellectual disability (previously called mental retardation)

Please check one of the boxes below:

YES, I HAVE A DISABILITY (or previously had a disability)
NO, I DON'T HAVE A DISABILITY
I DON'T WISH TO ANSWER

* Signature (type name):

* Date:

Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

ⁱSection 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor's Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

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