Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 7Employment ApplicationThis application will be actively considered for the position(s) indicated by the applicant for 90 days after submission to stlb™/PBI. Applications that list “open “or “anything” will NOT be considered. Applicants to be interviewed will be contacted by stlb™ HR DepartmentPersonal InformationPhone *Name *FirstMiddleLastHave you ever used a different name for work, school, or other purposes? *YesNoIf yes, please identify the name(s) used, the dates used, and the circumstances:Mailing Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *How did you hear about us?If you were referred by someone for the position you are applying for please provide the following information on the person that referred you:Reffered byFirstMiddleLastDaytime/Evening PhoneCompanyEmailIf you heard from us another way please take a minute and let us know how you heard about us:FaceBookInstagramLinkedInIndeedOtherIf Other please specify:Position DetailsPosition Applying For / Location *Date Available to Start *Expected Salary/Hourly Rate *Have you applied with us within the last 90 days? *YesNoIf hired, can you provide proof that you are at least 18 years of age? *YesNoGeneral InformationAvailable to Work (check all that apply) *Full-TimePart-TimeOvertimeHolidaysPreferred Shift *DaysEveningsNightsAre you legally eligible for employment in the U.S.? *YesNoDo you have relatives or friends currently working for stlb™? *YesNoIf yes, state their name, relationship to you, job title and location of employment. Have you ever applied for employment with or been employed by this company? *YesNoIf yes, list position(s) filled or applied forBackground InformationAll applicants MUST complete this portion. California and Hawaii applicants: See BelowHave you been convicted of, or pled “guilty,” “no contest” or “nolo contender” to a crime other than a minor traffic violation? *YesNoIf Yes Explain:California Applicants Only*When responding to background information section, California applicants should not disclose information concerning an arrest or detention that did not result in conviction, or information concerning a referral to, and participation in, any pretrial or post trial diversion program or any conviction for violation of subdivision (b) or (c) of Section 11357 of the Health and Safety Code or a statutory predecessor thereof (unauthorized possession of marijuana), or subdivision (b) of Section 11360 of the Health and Safety Code (formerly subdivision (c) of Section 11360 of the Health and Safety Code), or Section 11364, 11354, or 11550 of the Health and Safety Code as they relate to marijuana prior to January 1, 1976, or statutory predecessor thereof, two years from the date of such a conviction. As used herein, a “conviction” shall include a plea, verdict, or finding of guilty regardless of whether sentence is imposed by the court. As used herein, “pretrial or post trial diversion program” mean any program under Chapter 2.5 (commencing with Section 1000) or Chapter 2.7 (commencing with Section 1001) of Title 6 of Part 2 of the Penal Code, Section 13201 or 13352.5 of the Vehicle Code, or any other program expressly authorized and described by statute as a diversion program. (See California Labor Code section 432.7 subd. (a) and (j)). Signature (California) Clear Signature Date (California)Hawaii Applicants Only*Do not respond to background information section until you have been given a conditional offer of employment.Signature (Hawaii) Clear Signature Date (Hawaii)NextResume UploadI am uploading my resume belowCover Letter, Resume, & References Drag & Drop Files, Choose Files to Upload You can upload up to 3 files. Employment HistoryList all current and previous employment starting with your most recent position. Include all seasonal, part-time, and self-employment. You must complete this section even if you provide a resume. Failure to list complete and accurate information may result in disqualification or termination of employment.Company Name *Phone *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeJob Title *Start Date *End Date *Supervisor *Beginning Salary *End Salary *Major Duties *If applicable, list all other job titles and employment dates with this employerReason for Leaving *May we contact *YesNo-------------------------------------Company NamePhoneAddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeJob TitleStart DateEnd DateSupervisorBeginning Salary End SalaryMajor DutiesIf applicable, list all other job titles and employment dates with this employerReason for LeavingMay we contactYesNo-------------------------------------Company NamePhoneAddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeJob TitleStart DateEnd DateSupervisorBeginning SalaryEnd SalaryMajor DutiesIf applicable, list all other job titles and employment dates with this employerReason for LeavingMay we contactYesNo-------------------------------------Company NamePhoneAddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeJob TitleStart DateEnd DateSupervisorBeginning SalaryEnd SalaryMajor DutiesIf applicable, list all other job titles and employment dates with this employerReason for LeavingMay we contactYesNoNextHave you ever been discharged or asked to resign from a job? *YesNoIf yes, please explain each occasion when this has occurred listing company name, supervisor, reason, and date of occurrenceEducation HistoryHigh School Diploma/GED *YesNoList any college degrees, trade, certification, licenses, (etc.): *List any special skills: *NextConsumer Report AuthorizationIn making this application for employment, it is understood that a copy of a consumer report prepared by a consumer reporting agency may be obtained. Information from the report will not be used in violation of any federal or state equal opportunity law or regulation. I acknowledge receipt of a separate disclosure that a consumer report may be obtained. I hereby authorize a copy of my consumer report from a consumer-reporting agency to be sent to stlb™.Signature * Clear Signature Date *Verification AuthorizationI hereby authorize stlb™ to thoroughly investigate my background, any statement made on this application, references, employment record and other matters related to my suitability for employment. I authorize persons, schools, my current employer (if applicable), previous employers and organizations contacted by stlb™ to provide any relevant information regarding my current and/or previous employment and I release all persons, schools, employers of any and all claims for providing such information. I understand that misrepresentation and/or omission of facts regardless of when it is found, may result in rejection of this application or, if hired, termination of employment. I understand that nothing contained in this application, or conveyed during any interview which may be granted, is intended to create an employment contract. I understand and agree that my employment is at will, which means that it is for no specific period and may be terminated by stlb™ or me at any time without prior notice for any reason.Signature * Clear Signature Date *Certification StatementI certify that all of the information provided on this employment application and all additional sheets and resumes submitted to the stlb™/Premier Board, Inc. (Referred to as “stlb™/PBI”) is true, correct and complete. I understand that false, misleading, incomplete or omitted information on this application, attachments or resumes submitted to stlb™/PBI will result in rejection of this application or termination, if hired, regardless of the date of discovery.Signature * Clear Signature Date *Equal Opportunity and Affirmative Action EmployerSTLB is an Equal Opportunity/Affirmative Action employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, age or any other protected characteristic.NextVoluntary Self-Identification of DisabilityForm CC-305 • OMB Control Number 1250-0005 • Expires 05/31/2023 NameDateWhy are you being asked to complete this form?We are a federal contractor or subcontractor required by law to provide equal employment opportunity to qualified people with disabilities. We are also required to measure our progress toward having at least 7% of our workforce be individuals with disabilities. To do this, we must ask applicants and employees if they have a disability or have ever had a disability. Because a person may become disabled at any time, we ask all of our employees to update their information at least every five years. Identifying yourself as an individual with a disability is voluntary, and we hope that you will choose to do so. Your answer will be maintained confidentially and not be seen by selecting officials or anyone else involved in making personnel decisions. Completing the form will not negatively impact you in any way, regardless of whether you have self-identified in the past. For more information about this form or the equal employment obligations of federal contractors under Section 503 of the Rehabilitation Act, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp. How do you know if you have a disability?You are considered to have a disability if you have a physical or mental impairment of 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: •Autism •Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, or HIV/AIDS •Blind or low vision •Cancer •Cardiovascular or heart disease •Celiac Disease •Cerebral palsy •Deaf or hard of hearing •Depression or anxiety •Diabetes •Epilepsy •Gastrointestinal disorders, for example, Crohn’s Disease, or irritable bowel syndrome •Intellectual disability •Missing limbs or partially missing limbs •Nervous system condition for example, migraine headaches, Parkinson’s disease, or Multiple sclerosis (MS) •Psychiatric condition, for example, bipolar disorder, schizophrenia, PTSD, or major depressionPlease check one of the boxes below:Yes, I Have A Disability, Or Have A History/Record Of Having A DisabilityNo, I Don’t Have A Disability, Or Have A History/Record Of Having A DisabilityI Don’t Wish To AnswerPUBLIC 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. This survey should take about 5 minutes to complete.Nextstlb™ and Premier Board Inc. Voluntary Self-Identificationstlb™ is an Equal Opportunity Employer. As required by law, we must record certain information to be made a part of our Affirmative Action program. Completing this form is voluntary. Your answers will be kept private, and will not be used against you in any way. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, age or any other protected characteristic.Please complete the information requested below. Thank you for your cooperation. Section 1: General InformationNameDatePosition applied for:How did you hear about the position?Current EmployeeNewspaper AdState Agencystlb™ WebsiteOther? Please explainSection 2: Please check all that apply Race/Ethnic IdentityHispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.Black or African American: A person having origins in any of the black racial groups of Africa.Native Hawaiian or Pacific Islander: A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.American Indian or Alaskan 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.Two or More Races: All persons who identify with more than one of the above five races.I do not wish to self-identifyGenderMaleFemaleOtherI do not wish to self-identifyVeteran Status*I am a protected veteranI am NOT a protected veteranI do not wish to self-identify*This employer is a Government 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), which requires Government contractors to take affirmative action to employ Veterans. The Protected classifications are defined as follows: Vietnam Era Veteran – Veteran of the U.S. military, ground naval, or air service, and part of whose service was during the period August 5, 1964 through May 7, 1975, who (1) served on active duty for a period of more than 180 days and was discharged or released with other than a dishonorable discharge, or (2) was discharged or released from active duty because of a service connected disability. Also includes any veteran of the U.S. military, ground, naval, or air service in the Republic of Vietnam between February 28, 1961 and May 7, 1975. Disabled Veteran – Veteran who served on active duty in the U.S. military, ground, naval or air service, and: (1) is entitled to disability 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 (2) was discharged or released from active duty because of a service connected disability. Special Disabled Veteran – Veteran who was discharged or released from active duty because of a service connected disability, or 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% or more, or at 10% or 20% if the veteran has been determined to have a serious employment handicap. Other Protected Veteran – Any other veteran who served on active duty in the U.S. armed forces during a war or in a campaign or expedition for which a campaign badge has been authorized. Armed Forces Service Medal Veteran – 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. Wounded Warrior – A disabled veteran who has served on active duty after September 11, 2001, has fewer than 20 years of military service, has received either a Memorandum rating of 30% or greater from their service Physical Evaluation Board or a VA Service-connected disability rating of 30% or greater, and who is enrolled in the Wounded Warrior Program. Recently Separated Veteran – With respect to federal contracts and subcontracts entered into before December 1, 2003: Any veteran who served on active duty in the U.S. military ground, naval, or air service during the one year period or three year period beginning on the date of such a veteran’s discharge NextVoluntary SurveyDear Applicant: The mission of stlb™ is to Employ, Educate, and Empower our neighbors who are blind or visually impaired. Employ people who are blind or who have low vision, to Educate the world on the capabilities of those who are blind, and to Empower the blind to live full and rich lives. For employment purposes, we give first preference to those applicants that are blind or visually impaired as long as they are qualified for the position. Are you Legally Blind?YesNoSignature Clear Signature DatePhoneSubmit
