1. Employer: CheckPoint-ICS Inc.

Address: 801 N. Charles St., Ste 700/ P. O. Box 1572

City/State/Zip: Baltimore, Maryland 21201

Telephone: (443)708-8195/ Fax: (410) 566-9896 

It is the policy of CheckPoint-ICS Inc. to provide equal employment opportunities to all applicants and
employees without regard to any legally protected status such as race, color, religion, gender,
national origin, age, disability or veteran status. 

2. Applicant Name: ___________________________________________

Address: ___________________________________________

City/State/Zip: ___________________________________________

Number of years at this address: _________ 

Daytime phone: ____________________ Evening phone:  ____________________  

Social Security Number: ___________________________ 

3. Who should be contacted if you are involved in an emergency?

Contact Name: ___________________________________________

Relationship to you: ___________________________________________

Address: ___________________________________________

City/State/Zip: ___________________________________________

Daytime phone: ____________________ Evening phone:  ____________________   

4. Job Position Applied For: Laborers 

5. Referral Source:   Who referred you to our company?

___________________________________________________________ 

6. Have you applied to our company previously?  ______ Yes           ______ No

If yes, when? ________________________ 

7. Are you at least 18 years old? ______ Yes         ______ No   

8. How will you get to work? _____________________________________ 

9. Are you willing to work any shift, including nights and weekends? ______ Yes        ______ No

If no, please state any limitations:

________________________________________________ 

10. If you are offered employment, when would you be available to begin work?

____________________________________ 

11. Are you legally eligible for employment in the United States? ______ Yes       ______ No     

12. Are you able to perform the essential functions of the job position with
or without reasonable accommodation? ______ Yes        ______ No  

What reasonable accommodation, if any, would you require?

________________________________________________ 

13. Have you ever been convicted of any crime, including traffic violations?

______ Yes           ______ No If yes, please describe:

________________________________________________ 

THE EXISTENCE OF A CRIMINAL RECORD DOES NOT CONSTITUTE AN AUTOMATIC BAR TO EMPLOYMENT UNLESS RELEVANT TO THE TYPE OF EMPLOYMENT. 

14. Applicant Employment History: List your current or most recent employment first. 

Employer Name:  ___________________________________________

Address: ___________________________________________

City/State/Zip: ___________________________________________

Job Duties: ___________________________________________

Reason for Leaving: ___________________________________________

Dates of Employment (Month/Year): _____________________________ 


Employer Name:  ___________________________________________

Address: ___________________________________________

City/State/Zip: ___________________________________________

Job Duties: ___________________________________________

Reason for Leaving: ___________________________________________

Dates of Employment (Month/Year): _____________________________ 


Employer Name:  ___________________________________________

Address: ___________________________________________

City/State/Zip: ___________________________________________

Job Duties: ___________________________________________

Reason for Leaving: ___________________________________________

Dates of Employment (Month/Year): _____________________________ 

15. Applicant's Education and Training:  List your education and training. 

High School Name and Address

____________________________________________________________

Last Grade? ____ 9  ____ 10  ____ 11  ____ 12   Diploma? ______ Yes ______ No 

College Name and Address

____________________________________________________________

Did you receive a degree? ______ Yes  _____ No If yes, degree received:  ___________ 

Other Training (graduate, technical, vocational):

____________________________________________________________ 

Awards, Honors, Special Achievements:

____________________________________________________________ 

16.Applicant's Skills:  List any skills that may be useful for the job you are seeking.  Enter the number of years of experience, and circle the number which corresponds to your ability for each particular skill.  (One represents poor ability, while five represents exceptional ability.) 

      Ability or

      Skill Years of Experience Rating

17. References:  List any two people who would be willing to provide a reference for you. 

Name: ___________________________________

Address: ___________________________________

City/State/Zip: ___________________________________

Telephone: _______________________

Relationship: _______________________ 

Name: ___________________________________

Address: ___________________________________

City/State/Zip: ___________________________________

Telephone: _____________________________________

Relationship: ____________________________________ 

18. Please provide any other information that you believe should be considered:

____________________________________________________________

____________________________________________________________

CERTIFICATION 

I certify that the information provided on this Application is truthful and accurate.  I understand that providing false or misleading information will be the basis for rejection of my Application, or if employment commences, immediate termination. 

I authorize CheckPoint-ICS Inc. to contact former employers and educational organizations regarding my employment and education.  I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades.  I authorize those persons designated as references to fully and freely communicate information regarding my previous employment and education. 

If an employment relationship is created, I understand that unless I am offered a specific written contract of employment signed on behalf of the organization by its President/CEO, the employment relationship will be entirely voluntary in nature.  In other words, with appropriate notice, I will have the full and complete discretion to end the employment relationship when I choose and for reasons of my choice.  Similarly, my employer would have the same right.  Moreover, no agent, representative, or employee of CheckPoint-ICS Inc., except in a specific written contract of employment signed on behalf of the organization by its President/CEO, has the power to alter or vary the voluntary nature of the employment relationship. 

I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO ITS TERMS. 
 

____________________________________ _______________
APPLICANT SIGNATURE DATE