Application for Employment

First Name: (required)

First Last: (required)

Middle Name: (required)

Email: (required)

Phone: (required)

Location of Position Applying for?

Have you ever been convicted of a felony in the last 7 years? YesNo

Do you have relatives employed at Coastal Management Solutions?YesNo

Employment Experience

Please start with your current or last job. Please include any job-related military service assignments and volunteer activities. You may exclude organizations that indicate race, color, religion, gender, national origin, handicap or other protected status. If you need additional space, please continue on a separate sheet of paper. If you provide history information on a resume, please ensure that all of the requested information is provided.

First Employer Reference:

Company Name & Supervisor: (required)

Dates of Employmnet: (required)

Job Title: (required)

Hourly Rate/Salary: (required)

Reason For Leaving: (required)

Second Employer Reference:

Employer:

Dates of Service:

Job Title/Work Performed:

Employer Address (full address):

Hourly Rate/Salary:

Reason For Leaving:

Third Employer Reference:

Employer:

Dates of Service:

Job Title/Work Performed:

Employer Address (full address):

Hourly Rate/Salary:

Reason For Leaving:

Educational Background

Please list last three (3) schools attended, starting with the most recent.

1. School/Years Completed/Degree or Diploma/Major/Minor:

2. School/Years Completed/Degree or Diploma/Major/Minor:

3. School/Years Completed/Degree or Diploma/Major/Minor:

Please read the following statements. Your signature acknowledges that you have been truthful and completed this application to the best of your knowledge.

It is understood and agreed upon that any misrepresentation by me on this application will be sufficient cause for cancellation of this application and/or separation from the employer’s service if I have been employed.

I give the employer the right to investigate all references and to secure additional information about me, if job-related. I hereby release from liability the employer and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.

I will submit requested information and fingerprint cards and will cooperate will law enforcement personnel to aid in a swift and accurate police background check or security background check.

The employer is an Equal Opportunity Employer. The employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant’s consideration for employment on a basis prohibited by local, state or federal law.

This application is current for sixty (60) days. At the conclusion of this time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to complete a new application.

I understand that just as I am free to resign at any time, the employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the employer has the authority to make any assurances to the contrary.

Digital Signature/Date: (required)

The completion of the following section is not mandatory, but your cooperation is appreciated.

Voluntary Self-Identification of Disability

Form CC-305 OMB Control Number 1250-0005
Expires 05/31/2023

We are a federal contractor or subcontractor required by law to provide equal employment opportunity to qualified peoplewith disabilities. We are also required to measure our progress toward having at least 7% of our workforce be individualswith disabilities. To do this, we must ask applicants and employees if they have a disability or have ever had a disability. Because a person may become disabled at any time, we ask all of our employees to update their information at least every five years.

Identifying yourself as an individual with a disability is voluntary, and we hope that you will choose to do so. Your answer will be maintained confidentially and not be seen by selecting officials or anyone else involved in making personnel decisions. Completing the form will not negatively impact you in any way, regardless of whether you have self-identified in the past. For more information about this form or the equal employment obligations of federal contractors under Section 503 of the Rehabilitation Act, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

How do you know if you 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:
• Autism • Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, or HIV/AIDS • Blind or low vision • Cancer • Cardiovascular or heart disease • Celiac disease • Cerebral palsy • Deaf or hard of hearing • Depression or anxiety • Diabetes • Epilepsy • Gastrointestinal disorders, for example, Crohn's Disease, or irritable bowel syndrome • Intellectual disability • Missing limbs or partially missing limbs • Nervous system condition for example, migraine headaches, Parkinson’s disease, or Multiple sclerosis (MS) • Psychiatric condition, for example, bipolar disorder, schizophrenia, PTSD, or major depression

Please check one of the boxes below:

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

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.

Invitation to Self-Identify

This company is subject to Executive Order 11246, as amended, which requires Federal contractors to ensure that applicants and employees are treated without regard to their race, color, religion, sex, sexual orientation, gender identity, or national origin. We are therefore requesting information about race and gender in order to comply with government reporting requirements and in order to ensure equal employment opportunity.

Submission of this information is voluntary and will be kept confidential. Refusal to provide it will not subject you to any adverse treatment. The information provided will be used only in ways that are not inconsistent with Federal affirmative action regulations.

GENDER:
MALEFEMALEBLACK or AFRICAN AMERICAN (not Hispanic or Latino)HISPANIC OR LATINOASIAN (not Hispanic or Latino)AMERICAN INDIAN/ALASKA NATIVE (not Hispanic or Latino)NATIVE HAWAIIAN or PACIFIC ISLANDER (not Hispanic or Latino)TWO or MORE RACES (not Hispanic or Latino)I CHOOSE NOT TO SELF-IDENTIFY

This company is also 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 veterans in the following classifications:

• 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.

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 ABOVEI AM NOT A PROTECTED VETERANI CHOOSE NOT TO SELF-IDENTIFY

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