Service Application

General Information
Applicant Name*
First Middle Last
Phone*
Email
Current Address*
Street Address Address Line 2 City State ZIP Code
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Position
How did you hear about this position?*
Employee Name:
Are You Presently Employed?*
- Yes
- No
Date Available for Work:*
Expected Salary:*

Employment Record
List All Employment Starting With Most Recent
Most Recent Position Title*
Employer*
Start Date*
MM slash DD slash YYYY
End Date*
Final Salary*
Supervisor's Name*
First Last
Employer Phone Number*
Company Address
Street Address Address Line 2 City State ZIP Code
Position Description*
Reason For Leaving*
May We Contact This Employer?*
- Yes
- No
Previous Position
Former Position Title
Employer
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Final Salary
Supervisor's Name
First Last
Employer Phone Number
Company Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Position Description
Reason For Leaving
May We Contact This Employer?
- Yes
- No
Previous Position
Former Position Title
Employer
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Final Salary
Supervisor's Name
First Last
Employer Phone
Company Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Position Description
Reason for Leaving
May We Contact This Employer?
- Yes
- No
Previous Position
Former Position Title
Employer
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Final Salary
Supervisor's Name
First Last
Employer Phone
Company Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Position Description
Reason For Leaving
May We Contact This Employer?
- Yes
- No

Do you have Additional Work Experience?*
- Yes
- No
Previous Position
Former Position Title
Employer
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Final Salary
Supervisor's Name
First Last
Employer Phone
Company Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Position Description
Reason For Leaving
May We Contact This Employer?
- Yes
- No
Previous Position
Former Position Title
Employer
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Final Salary
Supervisor's Name
First Last
Employer Phone
Company Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Position Description
Reason For Leaving
May We Contact This Employer?
- Yes
- No
Military History
Have You Served In Any Branch of the Military?*
- Yes
- No
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Branch of Service
Beginning Rank
Ending Rank
Major Duties (Including Special Training)
Location(s) Assigned To

Voluntary Self-Identification Continued
RGC Resources is a Federal contractor subject to the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (“VEVRAA”). As a Federal contractor, we are required to take affirmative action to employ and advance in employment disabled veterans, recently separated veterans, Armed Forces service medal veterans and Active duty wartime or campaign badge veterans.

Definitions:

Disabled Veteran means (i) a veteran of the U.S. military, ground, naval or air service 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 Secretary of Veterans Affairs, or (ii) a person who was discharged or released from active duty because of a service-connected disability.

Active Duty Wartime or Campaign Badge Veteran means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized, under the laws administered by the Department of Defense.

Recently Separated Veteran means a veteran during the three-year period beginning on the date of such veteran’s discharge or release from active duty in the U.S. military, ground, naval or air service.

Armed Forces Service Medal Veteran means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985 (61 Fed. Reg. 1209).

If you believe you belong to any of the categories of protected veterans listed, please indicate by checking the appropriate box below. As a Government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.

Disclosure of your status as a covered veteran is voluntary. Choosing not to provide this information will not subject you to any adverse treatment.
Veteran Status:
- I identify as one or more of the classifications of Protected Veteran listed above
- I am not a Protected Veteran

Voluntary Self-Identification Continued
Why are you being asked to complete this form?

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities .To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

How do I know if I have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

Disabilities include, but are not limited to:

Blindness
Deafness
Cancer
Diabetes
Epilepsy
Autism
Cerebral Palsy
HIV/AIDS
Impairments requiring use of a wheelchair
Schizophrenia
Muscular Dystrophy
Major Depression
Multiple sclerosis (MS)
Missing limbs or partially missing limbs
Post-traumatic stress disorder
Obsessive compulsive disorder
Intellectual Disability (previously called mental retardation)
Disability Status:
Select One
- Yes, I have a disability (or previously had a disability)
- No, I do not have a disability
- I do not wish to answer
Reasonable Accomodation Notice
Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

If an offer of employment is made and, because of a physical or mental disability, you will need accommodation to perform any essential job function, please make the fact known to the individual processing your application.

i Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number.

Authorization and Release*
- I acknowledge that in the course of evaluating my application for employment, the Company will consider the results of a work and personal reference check, a criminal background check, a physical examination, and a pre-employment drug screening and, depending on the position for which I am applying, a credit check. I hereby consent to such testing and screenings. To this end, I do fully authorize all physicians, former employers, references and all other persons, firms, corporations, associations or institutions which have or will have control of any records or knowledge of infomation pertaining to me to provide the contents or copies of such records and such information to the Company. I do hereby release and exonerate every physician, former employer, reference and all other persons, firms, corporations, associations or institutions which shall furnish any records or information pertaining to me in compliance with this authorization, from any and all liability of every nature and kind.
Employment Eligibility*
- I understand that prior to employment I must furnish the Company acceptable documentation that I am legally eligible for employment in the United States.
I Consent to At-Will Employment*
- In consideration of my employment, I acknowledge that my employment is at-will and therefore my employment and compensation can be terminated with or without cause and with or without notice at any time at the option of the Company or myself. I understand that no representative other than the President has any authority to enter into any agreement for employment for any specified period of time or to make any agreement contrary to the foregoing, and any representations contrary to the foregoing are expressly disavowed and shall not be binding upon the Company and should not be relied upon by any prospective or existing employee unless made in writing and signed by the President. I further acknowledge that any personnel manual, handbook, publication, policy, procedure, rule or regulation that may now or in the future apply to me is not contractual in nature and is not intended to modify the foregoing employment relationship.
Falsified Information*
- I certify the facts contained in this application are true and complete, and, if employed by the Company, I understand and agree that I will be subject to dismissal if any answer given or information furnished by me on this application is false or incorrect.
Terms of Employment*
- I have carefully read, understand and agree to all of the provisions, terms and conditions contained in this application for employment.

Step 1 of 8 - General Information

General Information

Position

Employment Record

Previous Position

Previous Position

Previous Position

Previous Position

Previous Position

Military History

Education

Skills

Voluntary Self-Identification

Voluntary Self-Identification Continued

Voluntary Self-Identification Continued

Reasonable Accomodation Notice