Become a Dealer – Anchor Industries, Inc.

Equal Opportunity Information:*

Yes, I understand

Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodations to the application and/or interview process should notify a representative of the Human Resources Department. Anchor Industries, Inc. is an Equal Opportunity Employer, dedicated to a policy of non-discrimination in employment on the basis of age, sex, color, race, creed, national origin, religion, marital status (State of Florida), disability, disabled veteran or Vietnam Era Veteran status. Federal law prohibits the employment of unauthorized aliens. All persons hired must submit satisfactory proof of employment authorization and identity within three (3) days of being hired. Failure to submit such proof within the required time may result in immediate employment termination.

Position applied for:*

Todays Date:

Shifts you will not work:*

Primary Phone*

Name*

First Middle Last

Email*

Secondary Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Referred by

First Last

Are you 18 or older?*

Yes
No

Date available to start:

Have you ever been employed here before?*

Yes
No

If yes, give date(s):

Please list start and end dates (e.g. 01/01/2012 - 11/01/2011).

Are you legally eligible for employment in this country?*

Yes
No

Hourly wage or salary desired?*

Have you ever been convicted of a felony that has not been expunged by a court?*

Yes
No

Answering "yes" to these questions does not constitue an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation and position applied for will be taken into account.

If yes, please provide date(s):

If yes, please provide details:

Education

High School:*

College/University 1:

College/University 2:

Vocational/Technical School:

Employment Background A

Company Name:

Company Address:

Type of Business:

Dates Employed:

Company Phone:

Job Title:

Hourly Wage/Salary:

Describe your duties:

Reason for leaving:

Immediate supervisor:

May we contact?

Yes
No

Employment Background B

Company Name:

Company Address:

Type of Business:

Dates Employed:

Company Phone:

Job Title:

Hourly Wage/Salary:

Describe your duties:

Reason for leaving:

Immediate supervisor:

May we contact?

Yes
No

Employment Background C

Company Name:

Company Address:

Type of Business:

Dates Employed:

Company Phone:

Job Title:

Hourly Wage/Salary:

Describe your duties:

Immediate supervisor:

Reason for leaving:

May we contact?

Yes
No

Upload Resume:

Invitation to Self-Identify:

Yes, I choose to self identify
No, I decline

Self Identification

Name

First Last

Position applied for:

How were you referred for employment?

Anchor Employee Referral
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Other

If employee referral, name of person who referred you:

If advertisement, please list source:

If other referral, please explain:

Gender

Female
Male

Equal Opportunity identification group:

U.S. Military Veteran?

Yes
No

If U.S. Military Veteran, dates of military service:

Special disabled veteran?

Yes
No

Vietnam era veteran?

Yes
No

Other military veteran?

Are you a disabled person?

Yes
No

If yes, are there accommodations or do you need assistance to perform teh type of work you are requesting?

Are there skills or procedures you can use to perform the job, notwithstanding your disability? Please describe:

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Phone

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Education

Employment Background A

Employment Background B

Employment Background C

Self Identification

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