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Legal First Name

Middle

Legal Last Name

Date*

Street Address 1*

Street Address 2 (Apt. #)

City*

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Zip Code*

Phone Type*

Phone Number*

Phone Type

Phone Number

Email address*

Desired Employment

Desired Position*

Desired Salary*

Available Start Date*

Per*

Employment Information

Are you a U.S. Citizen?*

Are you authorized to work in the US?*

Have you ever been convicted of a felony?*

(This does not disqualify you from employment)

Please explain, in detail*

Have you ever worked for Grapevine in the past*

(This does not disqualify you from employment)

Last Date of Employment*

Reason for Leaving?*

Education

Please list all formal education, beginning with high school.

Type of School

From:*

To:*

Did You Graduate?*

Degree Received*

High School:*

College Attended*

Field of Study*

Type of School

From:*

To:*

Did You Graduate?*

Degree Received*

College Attended:*

Field of Study*

Type of School

From:*

To:*

Did You Graduate?*

Degree Received*

College Attended:*

Field of Study*

Previous Employment

If applicable, please provide three (3) years of verifiable work history

Are you currently Employed*

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No

Other

Current Supervisor*

Phone Number*

Supervisor Email*

May We Contact?*

Employer Address

Were You Employed Before This Job?*

Yes

No

Other

Supervisor*

Phone Number*

Supervisor Email*

May We Contact?*

Were You Employed Before This Job?*

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No

Other

Supervisor*

Phone Number*

Supervisor Email*

May We Contact?*

References

Please Include three (3) professional references

Reference 1

Reference 2

Reference 3

EEO-1 Voluntary Self Identification Form

The Equal Employment Opportunity Commission (EEOC) requires all private employers with 100 or more employees as well as federal contractors and first-tier subcontractors with 50 or more employees AND contracts of at least $50,000 complete an EEO-1 report each year. Covered employers must invite employees to self-identify gender and race for this report.

Completion of this form is voluntary and will not affect your opportunity for employment, or the terms or conditions of your employment. This form will be used for EEO-1 reporting purposes only and will be kept separate from all other personnel records only accessed by the Human Resources department. Please return completed forms to the HR department.

If you choose not to self-identify your race/ethnicity at this time, the federal government requires Grapevine Solutions Inc. to determine this information by visual survey and/or other available information.

Gender Identity

Please Select One:*

Race/Ethnicity

(Please check one of the descriptions below corresponding to the ethnic group with which you identify.)

Please Select One:*

Disability Identification

Please Select One:*

Is your disability one of the targeted disabilities listed below?*

Blind
Convulsive Disorder
Partial Paralysis
Deaf
Mental Retardation
Complete Paralysis
Missing Extremity (s)
Mental Illness
Genetic or physical condition affecting limbs or spine

Veteran Status

The U.S. Department of Labor (DOL), Veterans' Employment and Training Service (VETS) annually collects and compiles the Federal Contractor Veterans' Employment Report (VETS‐100) from federal contractors and subcontractors. Grapevine Solutions Inc. is an Equal Opportunity Employer and ensures its personnel processes provide for careful, thorough, and systematic consideration of the job qualifications of applicants and employees with known disabilities, and for covered Veterans, for job vacancies filled. Grapevine Solutions Inc. takes affirmative action to employ, advance in employment, and otherwise treat qualified individuals without discrimination based on their status as individuals with disabilities and/or Covered Veterans in all employment practices. Under the regulations implementing the affirmative action provisions of VEVRAA issued by the Office of Federal Contract Compliance Programs (OFCCP), a federal contractor is required to invite applicants and current employees to inform the contractor whether they are a Veteran belonging to one or more of the categories of Veterans covered under VEVRAA who wishes to benefit under the contractor's affirmative action program (AAP) for covered Veterans.

Electronic Signature*

Date*

Veteran Status*

Date of Discharge*

Type of Discharge*

Are You Retired From the Military?*

Date of Retirement*

Can You Identify as a Disabled Veteran?*

DISABLED VETERAN MEANS: 1‐ 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 Department of Veterans' Affairs for a disability (A) rated at 30 percent or more, OR (B) rated at 10 or 20 percent in the case of a Veteran who has been determined under Section 38 U.S.C. 3106 to have a serious employment handicap 2‐ A person who was discharged or released from active duty because of a service‐connected disability.

Can You Identify as a Vietnam Era Veteran?*

VETERAN OF THE VIETNAM ERA MEANS: A PERSON WHO: 1‐ Served on active duty in the U.S. military, ground, naval or air service for a period of more than 180 days and who was discharged or released with other than a dishonorable discharge, if any part of such active duty was performed: (A) In the Republic of Vietnam between February 28, 1961, and May 7, 1975; OR (B) Between August 5, 1964, and May 7, 1975, in all other cases. 2‐ Was discharged or released from active duty in the U.S. military, ground, naval or air service for a service‐connected disability if any part of such active duty was performed: (A) In the Republic of Vietnam between February 28, 1961, and May 7, 1975; OR (B) Between August 5, 1964, and May 7, 1975, in any other location.

Can you identify as Other Protected Veteran?*

OTHER PROTECTED VETERAN MEANS: Veterans 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 U.S. Department of Defense.

Can you Identify as a Recently Separated Veteran?*

(Veteran within 12 months from discharge or release from active duty)

Do you qualify for Veterans Preference?*

(The last war for which active duty is qualifying for Veterans preference is World War II (12‐7‐41 thru 4‐28‐52)

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information on my initial application or during my interview may result in my immediate release

Electronic Signature*

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Date*

Email address*

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Grapevine Solutions Career Application

Personal Information

Contact Information

Desired Employment

Employment Information

Education

Previous Employment

References

Reference 1

Reference 2

Reference 3

EEO-1 Voluntary Self Identification Form

If you choose not to self-identify your race/ethnicity at this time, the federal government requires Grapevine Solutions Inc. to determine this information by visual survey and/or other available information.

Gender Identity

Race/Ethnicity

Disability Identification

Veteran Status

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information on my initial application or during my interview may result in my immediate release

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