PERSONAL INFORMATION

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First
Middle Name
Street
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DEMOGRAPHIC INFORMATION

Please help us determine our compliance with State and Federal law by completing this section. The Company is an Equal Opportunity Employer. On a periodic basis the Company must report statistical information about applications and employees to the State and Federal governments to demonstrate that we meet equal opportunity requirements. Please note that if you leave the information blank, we have the right to enter data for equal opportunity statistical purposes based upon our visual observation. The information contained within this section will be kept confidential. It will not be used in any way to make any employment decisions.

1. To help us carry out our EEO/AA obligations, please indicate whether any of the following definitions apply to you.

Veteran: Veterans and unmarried widows and widowers of the veterans of the United States Armed Forces who have been honorably discharged and who have served from 9-16-40 to 12-31-46 or 6-27-50 to 1-31-55, or 8-5-64 to 5-7-75, or, for Persian Gulf War, from the period beginning on 8-29-90, and ending thereafter prescribed by Presidential Proclamation or by law, indicating the termination of the Persian Gulf War, or for those who have served in any expedition of the Armed Forces of the United States for which a medal was authorized shall be credited with a Veteran’s Preference.

Disabled Veteran: A person entitled to disability compensation under laws administered by the Veteran’s Administration for disability rated at 30 percent or more, or a person whose discharge or release from active duty was for a disability incurred or aggravated in the line of duty.

Individual with a Disability: A person who (1) has a physical or mental impairment which substantially limits one or more of such person’s major life activities, (2) has a record of such impairment, or (3) is regarded as having such an impairment.

2. Please answer below based upon how you identify yourself. We understand that it may be difficult to choose a single ethnic identity if you have a multi-cultural heritage. Nevertheless, to comply with legal guidelines, we would like you to choose only one.

White (not of Hispanic origin): A person having origins in any of the original peoples of Europe, the Middle East, or North Africa which includes people who identify as White, Irish, German, Italian, Lebanese, Near Easterner, Arab, or Polish.

Asian:A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent which includes people who identify as Asian Indian, Chinese, Filipino, Korean, Japanese, Vietnamese, or other Asian such as Burmese, Hmong, Pakistani or Thai.

Hispanic or Latino: A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race, such as Moroccan or Belizean.

American Indian or Alaska Native: A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.

Native Hawaiian or Pacific Islander: person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands which includes people who identify as Native Hawaiian, Guamanian or Chamorro, Samoan, Tahitian, Mariana Islander, or Chuukese.

Black or African American: (not of Hispanic origin): A person having origins in any of the Black racial groups of Africa which includes people who identify as Black, African American, Nigerian, Haitian.

Two or More Races: A person who identifies as a member of more than one race (i.e. White and Asian, Black and White, White and American Indian and Alaska Native).

Decline to State: A person who elects not to self-identify a race/ethnicity.

3. Please list language(s) other than English:

Vietnamese
Speak
Speak/Read
Speak/Read/Write
Cambodian
Speak
Speak/Read
Speak/Read/Write
Laotian
Speak
Speak/Read
Speak/Read/Write
Spanish
Speak
Speak/Read
Speak/Read/Write
Hmong
Speak
Speak/Read
Speak/Read/Write
Other Language:
Speak
Speak/Read
Speak/Read/Write

EMPLOYMENT DESIRED

Is there any information we would need about your name or use of another name for us to be able to check your work record?

Do you have any relatives who are presently (or were formerly) employed by the Company? If yes, please provide names and dates of employment.

If the position for which you are applying requires driving of any vehicle, provide the following:

Please note: You must be qualified, licensed, and insurable in order to hold any position that requires driving.

EDUCATION

EDUCATION Name and Location of School Major or Course of Study Number of Years Completed Certificate or Degree Earned
Last High School
Trade/Business/ Correspondence Schools
College(s)
Graduate School
SKILLS: List the skills and licenses (including numbers) you possess that are relevant to the position you seek. Use additional paper if needed.
Do you have any other skills that you believe would benefit the Company? Please list.
FORMER EMPLOYERS: (List employers below, most recent first, and describe employment for the last ten years. Indicate periods of unemployment and the reason(s). Use additional paper if necessary.)
Date(Month & Year) Employer’s Name, Address and
Telephone Number and Supervisor’s Name		 Hourly Rate/Salary Position and Duties Reason for Leaving
From:
To:
From:
To:
From:
To:

NOTE: Use the back of this sheet of paper to list additional employers if necessary. We will contact all of the employers listed on this application unless you specifically exclude them below.

Please list any employers you do not want us to contact and your reason for exclusion.

Employer’s Name
Reason
Employer’s Name
Reason

If employed, can you produce verification of your legal right to work in the United States? (New employees are required to produce documents that verify their legal right to work in the United States and to declare under penalty of perjury that these documents are their own and genuine.)

Have you previously worked for or applied for a position with the Company either as an employee or through an employment agency?

If yes, please explain when and, if employed, the position held:

REFERENCES:(Give the names of three persons whom you have known for at least one (1) year and who have personal, knowledge of your work skills and history. Do not include any relative unless the relative was your employer or manager and is identified.)

Name and Address
Business
How Long Acquainted

I, the undersigned, authorize the above-named references to respond to the Company’s request for confirmation of the information in this application, and for information about my skills, work history, reliability, honesty and any tendency to behave violently or in an unsafe, harmful or threatening matter. I hereby release the above-named references from all liability arising therefrom.

OTHER
What has been your greatest professional accomplishment in the past two years?
Please tell us about your hobbies and interests:

Have you been convicted of a felony in the past seven years, or a misdemeanor for which you are still on probation? Convictions for marijuana-related offenses that are more than two years old need not be listed.

If yes, please state the nature of the crime(s), when and where convicted, and the disposition of the case.

ACKNOWLEDGEMENT

EMPLOYMENT AT WILL

I understand that nothing contained in this Application, or conveyed during any interview that may be granted, is intended to create an employment contract for any specified period between Company and me. If hired, I understand that my employment relationship with the Company is at will, which means my employment may be terminated at any time, with or without cause or advance notice, by the Company or me, except as may be provided by an applicable Collective Bargaining Agreement or Barber’s Association Agreement. I also understand and agree that, if hired, the Company has the right to modify my position at its discretion. I further understand that my employment with the company shall be probationary for a period of 90 days, except as may be provided by an applicable Collective Bargaining Agreement or Barber’s Association Agreement

I further certify that answers given in this application are true and complete to the best of my knowledge. I understand that any false statements on this application could result in disqualification from the application process or if employed separation from the Company.

PLEASE NOTE: You should not rely upon a contingent offer of employment from the Company or otherwise engage in any activity based upon a contingent offer of employment. Unless or until an offer of employment is made that has no contingencies, you should not take any action that could result in financial loss if a contingent offer is withdrawn, such as giving notice of intent to terminate current employment, selling real estate, or incurring any other costs associated with accepting employment with the Company. No such activity should be undertaken until after you have been informed by the Company that the employment offer is no longer contingent.

PLEASE NOTE: Unless the Company specifically arranges otherwise with you, the Company considers applications only for a 30-day period. If you wish to be considered for employment after 30 days from the date of your application, please reapply.

The Company’s policy is to fill every position without regard to considerations made unlawful by federal, state or local laws, such as race, color, religious creed, sex, marital status, age over 40, national origin, ancestry, physical or mental disability, sexual orientation, medical condition, or any other consideration made unlawful by federal, state or local laws. The Company is an equal opportunity employer and selects employees on the basis of ability, experience, training, and character. Please contact the Company if you have any questions or complaints regarding this policy.

APPLICANT STATEMENT OF INDIVIDUAL WITH A DISABILITY, SPECIAL DISABLED VETERAN, AND VIETNAM ERA VETERAN

Gino Morena Enterprises is a government contractor subject to Section 503 of the Rehabilitation Act of 1973, as amended, and the Vietnam Era Veterans’ Readjustment Assistance Act of 1974 (VERAA), as amended, which require Government contractors to take affirmative action to employ and advance in employment qualified individuals with disabilities, special disabled veterans, and veterans of the Vietnam Era. If you have a disability, or are a special disabled veteran, or a Vietnam Era Veteran, we would like to include you under our affirmative action program. If you would like to be included under the affirmative action program, please tell us. You may inform us of your desire to benefit under the program at this time and/or any time in the future. This information will assist us in placing you in an appropriate position and in making accommodations for your disability. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information you submit about your disability will be kept confidential, except that (i) supervisors and managers may be informed regarding restrictions on the work or duties of individuals with disabilities and special disabled veterans, and regarding necessary accommodations; (ii) first aid and safety personnel may be informed, when and to the extent appropriate, if the condition might require emergency treatment; and (iii) Government officials engaged in enforcing laws administered by OFCCP or enforcing the Americans with Disabilities Act may be informed. The information provided will be used only in ways that are not inconsistent with section 503 of the Rehabilitation Act and the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended.

“Individual with a Disability” means any person who (1) has a physical or mental impairment which substantially limits one or more of such person’s major life activity; (2) has a record of such impairment; or (3) is regarded as having such impairment.

“Veteran of Vietnam Era” means a person who served on active duty for a period of more than 180 days and was discharged or released therefrom with other than a dishonorable discharge, if any part of such active duty occurred in the Republic of Vietnam between February 28, 1961 and May 7, 1975, or between August 5, 1964 and May 7, 1975, in all other cases. The term also refers to a person who was discharged or released from active duty for a service-connected disability if any part of such active duty was performed in the Republic of Vietnam between February 28, 1961 and March 7, 1975, or between August 5, 1964 and May 7, 1975, in all other cases.

A “Special Disabled Veteran” refers to a veteran who is entitled to compensation (or who, but for the receipt of military retired pay, would be entitled to compensation) under laws administered by the Department of Veterans Affairs for a disability rated at 30 percent or more, or rated at 10 or 20 percent in the case of a veteran who has been determined by the Department of Veterans Affairs to have a serious employment handicap. The term also refers to a person who was discharged or released from active duty because of a service-connected disability.