Application for Employment

The policy of Midstate Machine is to provide equal employment opportunities to all applicants and employees in all aspects of employmentwithout regard to race, color, religion, sex, age, creed, citizenship, alienage, national origin, ancestry, marital status, sexual orientation,physical or mental disability, veteran status, or any other characteristic protected under federal, state or local law.
Name
Address

IF NECESSARY FOR THE JOB I AM ABLE TO:

High School
Business/Technical
College/University
Other
EMPLOYMENT:

List last employment first. Include summer or temporary jobs. Be sure all your experience or employers related to this job are listed here.

Employer 1

Employer 2

Employer 3

For the purposes of this question, minor traffic offenses, infractions or citations, misdemeanors, expunged, or annulled convictions (including juvenile convictions or adjudications of delinquency), should not be included or considered. A conviction will not necessarily disqualify you from employment; the Company will consider additional factors including, but not limited to, the relationship between the conviction and the position applied for.

PLEASE READ ALL OF THE FOLLOWING CAREFULLY

I understand and agree that if I am offered employment, the offer will be conditioned upon the results of a medical examination which includes a drug test and that failure or refusal to take such test will disqualify me from further consideration for employment with Midstate Berkshire.


I understand and agree that if I am hired, my employment with Midstate Berkshire will be terminable "at-will". As an at-will employee, I understand and agree that I have the right to terminate my employment with the Company at any time, for any reason, with or without notice, with or without cause, and that the Company retains the same rights. If I am hired, I understand that all benefits, policies and procedures may be changed by the Company at any time, with or without notice. I understand that this application form, any and all policies, practices, and procedures of the Company, and all other communications provided or distributed to me by the Company, whether written or verbal, before hire or after I am employed, do not constitute or supplement any contract of employment. I further understand that no agent, employee, or representative of the Company has the authority to make any promise or agreement contrary to the foregoing, unless it is in writing and signed by an authorized executive officer of Midstate Berkshire.


I authorize the Company to investigate, verify and discuss all information set forth in my application, by contacting my prior employers and other references set forth above, and by any and all other means authorized or permitted by law, including any consumer and criminal background checks. I authorize the Company to request and obtain job-related information such as consumer reports, credit reports, investigative reports, and motor vehicle driving records, and make any other inquiries as to my character, reputation and ability as necessary for the Company to consider and evaluate my application for employment. I authorize any entity or person named in this application to provide the Company with any and all information in their possession, custody, or control regarding me, whether or not it is in their records, and to provide the Company with information that may be requested by the Company to arrive at an employment decision. I hereby release and agree to hold harmless the Company and its employees and agents from any and all claims that may arise as a result of taking any actions described herein. In addition, I hereby release and agree to hold harmless any and all individuals and entities who provide any information concerning me whether orally or in writing, in response to a request for such information from the company. A photocopy of this authorization shall be deemed as valid as the original.


If I am employed by Midstate Berkshire I will comply with all policies, rules and regulations implemented by the Company. I recognize that violation or non-compliance with any such policies, rules and regulations, or inappropriate or improper conduct or performance, may result in discipline up to and including termination of employment.


I hereby certify that the facts set forth above in my employment application are true and complete to the best of my knowledge. I understand that any omissions or false or misleading statements in this application or in interviews or other aspects of the hiring process will be grounds for my immediate disqualification from further consideration for employment or, if already employed, such information will be grounds for the immediate termination of my employment.


I understand and agree that the authorizations and agreements set forth above apply to Midstate Berkshire and its successors.


I have read the above and understand it.


EEO-1 Self-Identification Form

The employer is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, the employer invites employees to voluntarily self-identify their race and ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information will be kept confidential and will only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual.

As employers/government contractors, we also comply with government regulations including but not limited to affirmative action responsibilities as required under Executive Order 11246, Section 503 of the Rehabilitation Act of 1973, section 4212 of the Vietnam Era Veterans Readjustment Act of 1974 and Veterans Employment Opportunities Act (VEOA) of 1998.

This data is for periodic government reporting and will be kept in a Confidential File separate from the Application for Employment.



Name
Address

EEO-1 Survey

If you wish to be identified, please sign below and complete the survey:

  • served on active duty for a period of more than 180 days, and any part of which occurred between August 5, 1964 and May 7, 1975 and were discharged or released other than dishonorably; or,
  • was discharged or released from active duty for a service connected disability if any part of the active duty was performed between August 5, 1964 and May 7, 1975; or
  • 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 (such as The Persian Gulf, El Salvador, Grenada, Lebanon, Panama, Southwest Asia, Haiti, Somalia & Bosnia); or
  • one who served on active duty in the U.S. military, ground, naval or air service during the one-year period beginning on the date of discharge or release from active duty (recently separated veteran).