Employment Application

Step 1 of 7

Employment History
Provide employment information, including military service, for the last 15 years, starting with the most recent employer first. If you've held more than four jobs, provide this information on another sheet and attach to this Application Form.
Present or Last Employer
If current employer, may we contact?
- Yes
- No
Name of Employer
Phone Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employment Dates (Month/Year)
Current or Ending Pay Rate
Title of Position
Name and Title of Supervisor
Description of duties, responsibilities and significant accomplishments
Reason for leaving
Next Previous Employer
Name of Employer
Phone Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employment Dates (Month/Year)
Ending Pay Rate
Title of Position
Name and Title of Supervisor
Description of duties, responsibilities and significant accomplishments
Reason for leaving
Next Previous Employer
Name of Employer
Phone Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employment Dates (Month/Year)
Ending Pay Rate
Title of Position
Name and Title of Supervisor
Description of duties, responsibilities and significant accomplishments
Reason for leaving
Next Previous Employer
Name of Employer
Phone Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employment Dates (Month/Year)
Ending Pay Rate
Title of Position
Name and Title of Supervisor
Description of duties, responsibilities and significant accomplishments
Reason for leaving

References
(List three references other than relatives)
Name/Occupation*
Phone*
Years Known*
Address*
Street Address Address Line 2 City State ZIP Code
Name/Occupation*
Phone*
Years Known*
Address*
Street Address Address Line 2 City State ZIP Code
Name/Occupation*
Phone*
Years Known*
Address*
Street Address Address Line 2 City State ZIP Code
Conviction Record Status
All applicants and employees must, as a condition of employment, inform the organization of all convictions. This includes all convictions received within the past seven years, while your application for employment is pending, and within seven days of receiving a conviction if currently employed.
Have you been convicted of, and/or plead guilty to, a felony or misdemeanor in the past seven years?*
- Yes
- No
If you answered ‘yes’ and have been convicted of a felony or misdemeanor, please provide additional information below, such as the crime(s), date(s), court location, sentencing information, disposition of sentence, and rehabilitation completed. Please note that a ‘yes’ answer to this question does not necessarily disqualify an applicant for employment. Rather, such factors as age and date of conviction, seriousness and nature of the crime as it relates to the job applied for, and rehabilitation will be considered. The organization reserves the right to reject individuals for employment based on job-related convictions.
Date of Offense*
Date Format: MM slash DD slash YYYY
County and State in which Offense Occurred*
Conviction/Explanation*
Rehabilitation Completed*
Date of Offense
Date Format: MM slash DD slash YYYY
County and State in which Offense Occurred
Conviction/Explanation
Rehabilitation Completed
PLEASE READ CAREFULLY AND SIGN BELOW
I hereby certify that all of the information I have provided on this Employment Application is true and correct to the best of my knowledge. I understand that any misrepresentation or omission of facts will disqualify me from further consideration of employment, withdrawal of any offer of employment, or, termination of employment, if already hired.

I authorize verification of all of the information I have provided on this Employment Application and understand that additional information may be needed to consider my application for employment. I authorize all previous employers, educational institutions, references, and other persons who have knowledge of me or my records to provide any and all information pertinent to my employment and release the same from any liability resulting from providing such information. I also release this organization and all of its employees from all liability for any damage that may result from reliance on the information furnished.

The organization is committed to providing a drug and alcohol-free workplace. After receiving a conditional offer of employment, I understand that a drug test will be required before starting work. If the results of the test are positive, I understand that the offer of employment will be withdrawn.

I understand that if employed, I am required to abide by all policies, procedures, rules, and regulations of the organization. I also understand and agree that, if hired, my employment is “at-will” and is for no definite period and may, regardless of the date of payment of my wages or salary, be terminated by myself or the organization at any time with or without cause or notice.
Date*
Date Format: MM slash DD slash YYYY
Signature of Applicant*

CASA IMPORTS SUPPLEMENTAL APPLICANT INFORMATION
Please review the list of physical and mental requirements for Warehouse staff and driver positions. Are you able to perform these essential job duties with or without a reasonable accommodation?*
- Yes
- No
Applicant Signature*
Date*
Date Format: MM slash DD slash YYYY

MENTAL AND VISUAL DEMAND

High mental and visual attention required for reading product labels and product pick sheets, bills of lading for incoming shipments and operating product moving equipment.

EQUIPMENT AND MACHINERY OPERATED

Handcart, pallet jack, wrapping machine.

PHYSICAL DEMANDS

The physical demands described here are representative of those that typically are required by employees performing the essential functions of this position.

PHYSICAL ACTIVITY	Ave. Number of Hours Per Day				EXAMPLES OF PHYSICAL ACTIVITIES PERFORMED
PHYSICAL ACTIVITY	0-1 hours	1-3 hours	4-5 hours	6-8 hours	EXAMPLES OF PHYSICAL ACTIVITIES PERFORMED
Stand, and/or walk				X	Throughout the warehouse and to different product locations.
Use hands to finger, grasp, handle or feel				X	To stock shelves and or pick products according to order sheets.
Push with arms and upper extremities			X		To move products out of the way to select required products or make room on a shelf for product storage.
Pull with arms and upper extremities			X		To move products out of the way to select required products or make room on a shelf for product storage.
Reach with arms and/or hands		X			To select and to store products in designated warehouse location.
Stoop, kneel, crouch, or bend		X			To reach products for storage or selection.
Talk and/or hear				X	To interact with staff & customers
Repetitive motion of hands and/or wrists			X		For loading and unloading items on the trucks and at customer locations
Lifting food products 1-50 pounds				X	For loading and unloading products and picking products for delivery
Lifting food products 51-100 pounds			X		For loading and unloading products and picking products for delivery

Casa Imports
A Division of RLE Corp.
Verification Release

I hereby authorize, without liability, any person or organization, including but not limited to any educational institution, training facility or any institution, whose name I have given as a reference, or by whom I have been previously employed, to furnish Casa Imports (Company) any information they may have concerning my character, habits, ability, financial responsibility, job performance, reasons for leaving employment and all information concerning my employment or training to give such information to other companies and carriers requesting such information. Furthermore, there may be entities that the Company does business with may request investigative reports or consumer reports which apply to my background. In this case, these reports would apply to my assignment to projects related to the Customer, permission to be on the Customer’s premises and to handle it products and other security concerns of the Customer. I hereby release all such persons and organizations from any claims for damages of any kind, which may occur to me for reasons of furnishing such information. I hereby authorize any law enforcement agency or court of record to furnish Casa Imports information concerning Motor Vehicle Records, or any felony or misdemeanor for which I have been convicted.

Under the authority granted me by CFR Parts 40 and 382, I hereby authorize and require my previous and/or current employers by whom I was employed or to whom I applied for employment in the three year period preceding the date of the application to release the date, type of test and result of all drug and alcohol tests taken by me, including the date and type of test for any or any refusal by me to take a drug or alcohol test, to the Director of Drive Personnel, or Employment Placement Specialist assigned to process my application at Casa Imports. If I tested positive on any controlled substance test, had an alcohol test with a concentration of 0.04 or greater, or refused to take any drug or alcohol test, I also authorize the release of all information concerning my referral to a Substance Abuse Professions (SAP) including all records pertaining to my evaluation and treatment (if required by SAP). I authorize this release by whatever means is most expedient and agree to hold harmless any past employer or any person or company I applied with as well as their employees, agents, or representatives from all liability or damage that may arise from the release of the information specifically authorized here.

Applicant Rights (pursuant to 49CFR Part 391.23(i) effective October 29, 2004) I understand that I have the right to review information provided by my previous employers, to have errors corrected by the previous employers and resent to Casa Imports once corrected, and to have rebuttal statement attached to any alleged erroneous information should my previous employer and I not agree on the accuracy of the information. I further understand that the information provided by me will be used in making employment determinations and that my previous employers will be contacted for the purpose of investigating my safety performance history information ad required by paragraph (d) and (e) of 49CFR part 391.23. Request to review previous employer information must be in writing. A release form for employment records can be requested by calling (315) 724-4189 or mail to Driver Personnel-Information Request: P.O. Box 4429 Utica, NY 13504.
Name*
Social Security Number*
Signature*
Date*
Date Format: MM slash DD slash YYYY

CONFIDENTIAL
LAST NAME*
(PLEASE INCLUDE Jr., Sr., II, III Etc.)
FIRST NAME*
MIDDLE NAME*
I understand that in conjunction with my application for employment, Casa Imports, Inc. may use the services of an outside agency to research and verify the information I have provided on my application for employment including my personal background, character, professional standing, work history and qualifications. This agency will provide a written report of its findings to Casa Imports, Inc. Casa Imports, Inc. will use Advanced Drug & Alcohol Testing as an agent to perform its employment related background investigations.

Advanced Drug & Alcohol Testing may utilize various sources of information it deems appropriate including but not limited to: credit reporting agencies, worker’s compensation records including any and all injuries in compliance with the Federal ADA Act, Department of Motor Vehicle records, criminal conviction records, current and former employers, military records, educational records, professional and personal references. I request, authorize and consent to the release and disclosure of any and all information including but not limited to the above to, Advanced Drug & Alcohol Testing and Casa Imports, Inc.

I request, authorize and consent to the procurement of an Investigative Consumer Report and/or Consumer Credit Report and understand that they may contain information about my background, mode of living, character, personal characteristics and general reputation. This authorization in original or copy form shall be valid for one year from the date indicated next to my signature. According to the Fair Credit Reporting Act, I will be notified by, Casa Imports, Inc. if employment is denied because of information obtained from a Consumer Reporting Agency. Additionally, I understand that if requested within 60 days, I will be given a full and accurate disclosure as to the nature and substance of all information provided to Casa Imports, Inc.

Law enforcement agencies and other entities require the following information when checking public records. It is confidential and will not be used for any other purposes. I hereby release Casa Imports, Inc. and Advanced Drug & Alcohol Testing, its agents and all persons, agencies and entities providing information or reports about me from any liability arising out of the request for or release of any of the above-mentioned information or reports.
Signature*
Today’s Date*
Date Format: MM slash DD slash YYYY
Position Applied For*
Social Security Number*
Date of Birth*
Date Format: MM slash DD slash YYYY
Driver’s License #*
State*
Other names you have used or are also known as:
Previous Addresses*
List all addresses where you have lived for the past 10 years starting with current address.

Resume
Attach Your Resume*
Drop files here or

Accepted file types: doc, docx, pdf, rtf, txt, odt, wps.

Step 1 of 7

Biographical Data

Educational Background

High School

College

Other

Skills

Employment History

Present or Last Employer

Next Previous Employer

Next Previous Employer

Next Previous Employer

References

Conviction Record Status

PLEASE READ CAREFULLY AND SIGN BELOW

CASA IMPORTS SUPPLEMENTAL APPLICANT INFORMATION

MENTAL AND VISUAL DEMAND

EQUIPMENT AND MACHINERY OPERATED

PHYSICAL DEMANDS

Casa Imports
A Division of RLE Corp.
Verification Release

CONFIDENTIAL

Resume

Step 1 of 7

EMPLOYMENT APPLICATION

Biographical Data

Educational Background

High School

College

Other

Skills

Employment History

Present or Last Employer

Next Previous Employer

Next Previous Employer

Next Previous Employer

References

Conviction Record Status

PLEASE READ CAREFULLY AND SIGN BELOW

CASA IMPORTS SUPPLEMENTAL APPLICANT INFORMATION

MENTAL AND VISUAL DEMAND

EQUIPMENT AND MACHINERY OPERATED

PHYSICAL DEMANDS

Casa Imports A Division of RLE Corp. Verification Release

CONFIDENTIAL

Resume

Casa Imports
A Division of RLE Corp.
Verification Release