PLEASE ENTER INFORMATION AND COMPLETE THIS APPLICATION FORM
Position(s) Applied For:
Name (Please enter First Name and Middle Name in first field)
Address Line 2
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
British Indian Ocean Territory
Central African Republic
Democratic Republic of the Congo
Republic of the Congo
Papua New Guinea
Saint Kitts and Nevis
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
United Arab Emirates
United States Minor Outlying Islands
Virgin Islands, British
Virgin Islands, U.S.
Email address (Please double check that you type it correctly):
How Did You Hear About Us?
If "Other", please specify.
Are you legally eligible to work in the United States?
(Proof of eligibility will be required upon offer of employment)
Are you over the age of 18 years?
(If no, you may be required to provide authorization)
Do you have a valid driver's license?
Number of moving violations in the last 5 years:
Please provide your personal vehicle information: Make, Model, Year
Have you ever applied to Optima before?
Have you ever worked for Optima before?
Is anyone related to you employed by Optima?
If yes, please give their name and relationship to you.
What salary or rate of pay do you expect to receive if employed?
($ _______ per ______ )
Have you ever been fired or asked to resign from a job?
If yes, please explain:
On what date would you be available to work?
Days and Hours Available, please be as specific as possible
Day Sunday Monday Tuesday Wednesday Thursday Friday Saturday
AM / PM
(Example: Monday - 9:00 AM to 2:30 PM)
Education. Please specify below: Name and Location of School / Course or Major of Study / Number of Years Completed / Diploma or Degree for: High School, College, Graduate, Vocational
Please describe any specialized training apprenticeships, licenses or skills
Employment History (Begin with current or most recent employer. Do not exclude any employment. Include any applicable temporary employment. Previous salaries or wages will not be used to determine compensation at Optima). Please be as specific as possible base on the information requested below:
1. Company Name / 2. Employment Dates (From _____ to _______ ) / 3. Salary / 4. Name and Title of supervisor / 5. Address / 6. Phone / 7. Describe your position and duties / 8. Reason and explanation for leaving
Second Employment History (Do not exclude any employment. Include any applicable temporary employment. Previous salaries or wages will not be used to determine compensation at Optima). Please be as specific as possible base on the information requested below:
1. Company Name / 2. Employment Dates (From _____ to _______ ) / 3. Salary / 4. Name and Title of supervisor / 5. Address / 6. Phone / 7. Describe your position and duties / 8. Reason and excplanation for leaving
Third Employment History
Fourth Employment History
References. Please list three persons with contact info. (These should be persons who are not related to you, who can provide professional references.)
I hereby certify that all of the information provided by me in this application is correct, accurate and complete to the best of my knowledge. I understand that the falsification, misrepresentation or omission of any facts may be cause for denial of employment.
Application of Voluntary Self-Identification
As an equal opportunity affirmative action employer, the following is being gathered, not for employment decisions, but for record-keeping in compliance with federal laws and regulations. We ask you to voluntarily assist us in our effort to collect the most accurate data by checking below your gender and the one ethnic group with which you most closely identify.
Providing this information is voluntary, and your emplyoment opportunities will not be adversely affected if you respond or decline to respond. If you choose not to self-identify, your gender and ethnicity will be recorded by a company representative based on visual observation. This information will be kept separate and confidential and will only be used in accordance with government and other legal reporting requirements.
To assist in appropriate identification, you may mark the group to which you belong, identify with, or are regarded in the community as belonging to, as defined below:
(1) White (Not Hispanic or Latino): A person having origins in any of the original peoples of Europe, the middle East, or North Africa.
(2) Black or African American (Not Hispanic or Latino): A person having origins in any of the black racial groups of Africa.
(3) Hispanic or Latino: All persons of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
(4) Asian (Not Hispanic or Latino): A person having origins in any of the original peoples of the Far East, Southeat Asia, or the Indian Subcontinent.
(5) Amer. Indian or Alaska Native: A person having origins in any of the original people of NSAM and who maintained tribal affl. or comty. atchmt.
(6) Native Hawaiian or Pacific Islander: A person having origins in any of the origins of Hawaii, Guam, Samoa, or other Pacific Island.
(7) Two or More Races: All persons who identify with more than one of the above five races.
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