Application for Employment

(All Information Treated Confidential)

We are an equal opportunity employer. No applicant or employee shall be discriminated against by reasons of race, sex, age, religion, color, national origin, or disability.

INSTRUCTIONS: All applications for employment with Rainbow Omega, Inc., must be made on this form. Applicants are urged to consider carefully and understand fully each question, and having done so, to fill in all blanks accurately. All information submitted is subject to verification. A false or misleading response may result in disqualification. This application will be considered only for the specific job identified. Should the applicant desire consideration for other jobs in the future, the applicant should submit other applications at the proper time. An unsigned or incomplete application will not be considered.

Position Applied For

First Name

Middle Name

Last Name

(May be used for official correspondence.)

Mailing Address

City

State

Zip

Dates Lived Here

Primary Phone

Secondary Phone

Social Security Number

Drivers License Number/State

Are you a Citizen of the United States?

Are you available to work:

(Check all that apply)

Full-time Overtime Part-time Requiring Travel

When could you begin work?

List any reasons known to you why you might be unable to perform the duties and responsibilities of the job you are applying for. A list of requirements will be provided for each job.

Education:

Type of School	Name of School, City, & State	Years Completed	Graduated?	Degree
GED			Yes
High School			Yes
College / University			Yes
Other (Specify)			Yes

What was your Major Field of Study?

Special Qualifications & Skills:

List qualifications and skills you possess which you wish to be considered or which are required in the job for which you are applying.

Example: Drivers License (give type and number); Computer; typing or shorthand proficiencies; ability to operate specialized equipment or machines or professional registration or licensing, (give type and number).

Why do you want to work for Rainbow Omega, Inc.?

Work Experience:

Start with present or most recent job and list all job history. Include military service.

Present or Most Recent Employer

Employer’s Name

Employer’s Address

Employer’s City

Employer’s State

Employer’s Zip

Employer’s Phone

Type of Business

Supervisor’s Name

Dates Employed

From:

To:

Job Title

Reason for Leaving

Description of Duties

[+] Add Another Employer

Employer 2

Employer’s Name

Employer’s Address

Employer’s City

Employer’s State

Employer’s Zip

Employer’s Phone

Type of Business

Supervisor’s Name

Dates Employed

From:

To:

Job Title

Reason for Leaving

Description of Duties

[+] Add Another Employer

Employer 3

Employer’s Name

Employer’s Address

Employer’s City

Employer’s State

Employer’s Zip

Employer’s Phone

Type of Business

Supervisor’s Name

Dates Employed

From:

To:

Job Title

Reason for Leaving

Description of Duties

[+] Add Another Employer

Employer 4

Employer’s Name

Employer’s Address

Employer’s City

Employer’s State

Employer’s Zip

Employer’s Phone

Type of Business

Supervisor’s Name

Dates Employed

From:

To:

Job Title

Reason for Leaving

Description of Duties

[+] Add Another Employer

Employer 5

Employer’s Name

Employer’s Address

Employer’s City

Employer’s State

Employer’s Zip

Employer’s Phone

Type of Business

Supervisor’s Name

Dates Employed

From:

To:

Job Title

Reason for Leaving

Description of Duties

[+] Add Another Employer

Employer 6

Employer’s Name

Employer’s Address

Employer’s City

Employer’s State

Employer’s Zip

Employer’s Phone

Type of Business

Supervisor’s Name

Dates Employed

From:

To:

Job Title

Reason for Leaving

Description of Duties

[+] Add Another Employer

Employer 7

Employer’s Name

Employer’s Address

Employer’s City

Employer’s State

Employer’s Zip

Employer’s Phone

Type of Business

Supervisor’s Name

Dates Employed

From:

To:

Job Title

Reason for Leaving

Description of Duties

[+] Add Another Employer

Employer 8

Employer’s Name

Employer’s Address

Employer’s City

Employer’s State

Employer’s Zip

Employer’s Phone

Type of Business

Supervisor’s Name

Dates Employed

From:

To:

Job Title

Reason for Leaving

Description of Duties

[+] Add Another Employer

Employer 9

Employer’s Name

Employer’s Address

Employer’s City

Employer’s State

Employer’s Zip

Employer’s Phone

Type of Business

Supervisor’s Name

Dates Employed

From:

To:

Job Title

Reason for Leaving

Description of Duties

[+] Add Another Employer

Employer 10

Employer’s Name

Employer’s Address

Employer’s City

Employer’s State

Employer’s Zip

Employer’s Phone

Type of Business

Supervisor’s Name

Dates Employed

From:

To:

Job Title

Reason for Leaving

Description of Duties

May inquiry be made of your present employer regarding your character, qualifications, and a record of employment?

If you answer “Yes” to any of the following, explain below. Yes No

No employee of Rainbow Omega, Inc. shall have any financial interest in the profits of any contract, service or other work performed by ROI, nor shall personally profit directly or indirectly from any contract, purchase, sale or service between ROI and any person or company. Is there any present or potential conflict of interest between you and any member of your family and ROI’s operation?

Have you been fired or asked to resign from a job within the last five years?

Have you ever been discharged from the armed forces under other than honorable conditions?

Have you ever been convicted of a crime?

A criminal record will not necessarily disqualify you from employment, unless you have been convicted of a felony child or elderly abuse or neglect. Your case will be considered in relation to requirements of Rainbow Omega’s licensing agencies.

Are you now working or have you previously worked for Rainbow Omega, Inc.?

Do you, or does your spouse, have any relative presently working for Rainbow Omega, Inc. or serving as a member of the Board of Directors for Rainbow Omega, Inc.?

Explanation and/or comments for “yes” answers above:

References:

I wish to list the following as personal references: (Please do not list relatives or former employers.)

Reference #1

Reference’s Name

Reference’s Address

Reference’s City

Reference’s State

Reference’s Zip

Reference’s Phone

Reference’s Email

Relationship

How long have you known this person?

Reference #2

Reference’s Name

Reference’s Address

Reference’s City

Reference’s State

Reference’s Zip

Reference’s Phone

Reference’s Email

Relationship

How long have you known this person?

Reference #3

Reference’s Name

Reference’s Address

Reference’s City

Reference’s State

Reference’s Zip

Reference’s Phone

Reference’s Email

Relationship

How long have you known this person?

APPLICATION CERTIFICATION:

I UNDERSTAND AND AGREE:

I certify that the statements and information contained herein is true, complete, and correct to the best of my knowledge. The information given in this application is given of my own free will. I understand that the Chief Executive Officer or the Director of Operations of Rainbow Omega, Inc. in making hiring decision is relying upon my responses to all questions on this application and during the entire application process. Any material misrepresentation or deliberate omission of requested information in my application may be justified for refusal of, or if employed, termination from employment.
I understand that an incomplete application will not be considered.
I understand, except as otherwise requested in my application regarding my current employer, this is my expressed permission for Rainbow Omega’s Chief Executive Officer or his designee to contact prior employers to obtain any and all information related to my past work performance. It is my understanding that Rainbow Omega, Inc will make a thorough investigation of my work and personal history and may verify all data given in my application for employment, related papers or oral interviews.
I understand that my employment may be terminated by the Chief Executive Officer or the Director of Operations of Rainbow Omega, Inc at any time without liability for wages or salary except such as may have been earned at the date of such termination.
I understand that although management makes every effort to accommodate individual preferences, business needs may at times make the following conditions necessary: overtime, rotating work schedule or a work schedule other than Monday through Friday.
I understand that if offered employment, my employment may be contingent upon the negative results of a pre-employment drug screen. Upon receipt of a confirmed positive result, your employment offer will be withdrawn and you will no longer be considered for employment. I also consent to submit to periodic random and reasonable suspicion drug and/or alcohol testing by ROI if hired.
I further understand that this is an application for employment and that no employment contract is being offered.
I understand that if I am employed, such employment is for an indefinite period of time, and that the Board of Directors of Rainbow Omega, Inc. can change wages, benefits, and conditions at any time.
I understand that Rainbow Omega, Inc. is a non-smoking facility. Therefore, I understand that I will not be able to smoke while on duty or on the premises of Rainbow Omega, Inc.

Signature

Date