Cord Camera: Employment Application

Employment Application

Please read all instructions carefully before proceeding to fill out the online application.

Due to the large volume of applications, no phone calls will be accepted to confirm that your application was  received. It generally takes us two weeks to get through the online applications. If you are not sure that your application was received please mail one to:

Human Resources
Cord Camera
745 Harrison Drive
Columbus, Ohio 43204

All applications and resumes are kept on file for one year.
Thank You for your interest in Cord Camera.
- Human Resources Department

General Information

First Name:

Middle Name:

Last Name:

Street Address 1:

Street Address 2:

City:

State:

Zip Code:

Area Code and Phone:

E-mail Address:

Are you a U.S. citizen?
Yes No

Do you have an Alien Registration Receipt Card Form 1-151?      Yes No N/A

Employment Sought

Position applying for:

If other, please specify:
  Do you wish to work:

Preferred Location:

Full Time
Part Time

 Any
Seasonal

Days and Hours desired:

Would you be willing to work other days or shifts if your first choice is not available? Yes No

Date available to start work:

List any limitations you may have concerning unavailability for particular shifts or unavailability for overtime? (if none, so state)

Education

Name and location of high school:

Name and location of college:

If not a high school graduate,
do you have a G.E.D.?

Yes No N/A

If yes, date and place obtained:

List any schools, training or
special interest:

Employment History

List below all present and past employment, beginning with your most recent.  Include all jobs, even part time jobs and jobs held for short periods of time.

Employer 1

Employed    From Mo/Yr    To Mo/Yr       Pay $   Per

Name of Employer:

Position Held:

Why did you leave?
Employer Phone Number:

Address (optional):

Employer 2

Employed    From Mo/Yr    To Mo/Yr       Pay $   Per

Name of Employer:

Position Held:

Why did you leave?
Employer Phone Number:
Address (optional):

Employer 3

Employed    From Mo/Yr    To Mo/Yr       Pay $   Per

Name of Employer:

Position Held:

Why did you leave?
Employer Phone Number:
Address (optional):

Employer 4

Employed    From Mo/Yr    To Mo/Yr       Pay $   Per

Name of Employer:

Position Held:

Why did you leave?
Employer Phone Number:
Address (optional):

Background Questionnaire

Have you been employed by this company before?
Yes No

In the past 10 years, have you been fired or asked to resign from a job?
Yes No

Have you ever been convicted of a crime, other than a minor traffic violation? 
Yes No

If yes, explain (place, date, circumstances) Note: A criminal record is not an automatic bar to employment.

Driving Record

Do you have a car now?
Yes No

If you are applying for a Distribution Center or General Labor position, has your driver's license in this or any other state been suspended or revoked? 
Yes No

If yes, explain. Give dates, place and reason.

Medical

If you are applying for a job as a Photo Lab Technician, do you have any visual restrictions?

Defective Sight:
Yes No

Color Blindness:
Yes No
 

USMA United States Mutual Association
EMPLOYMENT SCREENING RELEASE FORM
APPLICANT INFORMATION Please Complete

Name:
First:

Middle:

Last:

Other Name(s) Used:

Present Address: Street:

City:

State:

Zip Code:

Phone:

  

Previous Address: Street:

City:

State:

Zip Code:

Phone:

Drivers License Number:

Date Of Birth:

 Year

Social Security #:

APPLICANT  Read Carefully

AUTHORIZATION TO RELEASE CRIMINAL HISTORY INFORMATION REPORTS, PRIVATE COMPANIES’ DISHONESTY, DRUG OFFENSE OR VIOLENCE REPORTS, OR CREDIT BUREAU REPORTS or MOTOR VEHICLE REPORTS. For and in consideration of my being considered for employment, I hereby authorize the company designated below ("Employer") to make inquiries to United States Mutual Association (USMA), a consumer reporting agency, or any consumer reporting agency (CRA), concerning my employment suitability and qualification; including: (i) any public record of any arrest or convictions for crimes of violence or dishonesty; (ii) any incidents of employment dishonesty, retail theft, or other employment related acts of dishonesty, violence or drug related offenses reported to USMA or any other CRA, by any merchant or employer where such acts occurred; or (iii) any credit bureau reports; or (iv) department of motor vehicle reports. I further authorize any governmental agency where such arrest or conviction information is on file, or any company ("Prior Company") where such incident or credit transaction occurred, and USMA, or any other CRA to disseminate such report(s) to Employer. During any period(s) while I may be employed by Employer, I hereby authorize Employer to make further like inquiries to USMA or any other CRA as Employer may, from time to time, deem necessary for employment purposes. I also hereby authorize USMA or any other CRA, any such governmental agency, any such credit bureau, and such Prior Company to issue such reports in response to Employer’s inquiry(ies). I waive any further notice with respect to Employer’s inquiries or with respect to such governmental agency’s, such Prior Company’s, such credit bureau’s, USMA’s, or any other CRA’s, dissemination of any such report(s). I hereby generally release and fully discharge Employer, USMA and any other CRA, every such governmental agency, any such credit bureau, and such Prior Company from and against any and all liability with respect to, or arising from, the release or dissemination of any such information for such purposes. I understand and agree that my employment, promotion, or retention may be determined, in whole or in part, based on the report(s) so issued to Employer by USMA or any other CRA. I have been informed and I understand that I will be provided a copy of such report and that I may dispute the accuracy or completeness of the information reported to Employer by writing or calling USMA at the address or telephone number listed below or the applicable Consumer Reporting Agency.

In lieu of a signature, by checking yes below you authorize Cord Camera to obtain Criminal History Information Reports, Private Companies’ Dishonesty, Drug Offense or Violence Reports, or Credit Bureau Reports or Motor Vehicle Reports

DO YOU AGREE TO THE ABOVE
AUTHORIZATION TO RELEASE:

YES
NO

TODAY'S DATE:
 

EMPLOYER SECTION
EMPLOYER Mandatory Information

EMPLOYER/COMPANY:   CORD CAMERA CENTERS
CORD LOCATION:  ____________________________

INTERVIEWER:  _______________________________  PHONE:          -                          Ext.  _______

Company’s Certification: Employer hereby certifies to United States Mutual Association (USMA) that it is requesting a consumer report(s) on the applicant named above and that Employer will use the report(s) only for employment purposes.

EMPLOYER Screening Services Requested

  USMA Theft Database

  Employment-Related Credit Report

  Motor Vehicle Report   From What State:  ____________________

  County Criminal Record Search

          In the county where the Applicant resides

          If different, in the county where Employer’s hiring location is situated

               In the county of:  __________________________  In the state of:  ____________________

               In the county of:  __________________________  In the state of:  ____________________

               In the county of:  __________________________  In the state of:  ____________________

USMA Employment Screening Center  4500 S. 129th E. Avenue, Tulsa, OK 74134-5885
Phone: (800) 570-4831   Fax: (888) 704-8762  E-Mail: Westlake@usmutual.com

CERTIFICATION

The facts set forth above in my application for employment are true and complete.

EMPLOYMENT AT WILL STATEMENT

I understand and agree that any employment relationship that I may enter into the Cord Camera Centers is at will. In other words, I may leave at any time, for any reason, and Cord Camera Centers may terminate my employment at any time, for any reason or no reason.

AUTHORIZATION

I further understand and agree that if I am employed by Cord Camera Centers, the company may use my picture, or any reproduction thereof, in a newspaper advertisement, flier, brochure or any other form of advertising, the company wishes to use.
You are hereby authorized to make any investigation of my personal history and credit record through any investigative or credit agencies of your choice. I authorize the release of any and all records & information concerning me to include: credit & financial records, employment records, medical records, military records, motor vehicle records, criminal records, school records and personal data. I authorize any firm, person or government agency to release any of the above information. I release from liability any person who furnishes information in connection with this form. A copy of this form shall be as valid as the original.
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