EMPLOYMENT APPLICATION
Our Equal Employment Opportunity Commitment: Vertex Inc. considers applicants for all positions without regard to
race, color, religion, sex, national origin, age, marital status, veteran status, disability, or other any characteristic
protected by law. In addition, no information obtained by Vertex Inc. in response to any question in this application will
be used in violation of any federal, state or local law.
Instructions:
1. Print neatly in ink.
2. Complete all items on the application accurately. Inaccurate information may disqualify your application.
3. Even if you attach a resume, complete all items. Attach an additional sheet of paper if required to complete
any of the sections.
 Any applicant with a disability who needs a reasonable accommodation to participate in the application process
should contact the Human Resources Department.
Applicant Information
Name:
(Last)
(First)
(M.I.)
Other Name(s):
(used at other employers, military or schools)
Current Address:
(Street)
(City)
(State)
(Zip)
(Street)
(City)
(State)
(Zip)
Prior Address:
Telephone Number: (
)
(
)
Email Address:
Are you 18 or over?
 Yes
 No
If no, state birth date
(Month/Day/Year)
Are you eligible for employment in the United States?…………….……………………………………..............  Yes
 No
Do you now, or will you in the future need sponsorship from an employer in order to obtain, extend or
renew your authorization to work in the United States?.................................................................................  Yes
 No
If yes, please provide details
Employment Desired
Position:
Date Available:
Salary Desired: $
How did you hear about the position?:
(newspaper ad, referral, temporary agency, internet, etc.)
If referred by a current employee, employee’s name:
Have you ever applied to Vertex Inc.?………….…………………………….…………………………………..  Yes
If yes, where?_______________________
When? ______________
What position?
Have you ever been employed by Vertex Inc.?………………………………………………………...  Yes
If yes, where? __________________________ When? _______________ What position?
Vertex Inc.
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 No
 No
Employment, Military and/or Voluntary Work Information
Starting with your most recent position, list all employment including self-employment, part-time work, temporary work,
full-time military service, and any volunteer work (during periods where you were not employed for pay).
If currently employed, can we contact your present employer for a reference at this time?
Employer Name:
Job Title:
Address:
Supervisor:
 Yes
 No
Base Salary: $
$
Starting
Phone #:
Responsibilities/Accomplishments:
Employed:
Ending
(Mo/Yr)
(Mo/Yr)
Reason for Leaving:
Employer Name:
Job Title:
Address:
Supervisor:
Base Salary: $
$
Starting
Phone #:
Responsibilities/Accomplishments:
Employed:
Ending
(Mo/Yr)
(Mo/Yr)
Reason for Leaving:
Employer Name:
Job Title:
Address:
Supervisor:
Base Salary: $
$
Starting
Phone #:
Responsibilities/Accomplishments:
Employed:
Ending
(Mo/Yr)
(Mo/Yr)
Reason for Leaving:
Employer Name:
Job Title:
Address:
Supervisor:
Base Salary: $
$
Starting
Phone #:
Responsibilities/Accomplishments:
Vertex Inc.
Employed:
Ending
(Mo/Yr)
(Mo/Yr)
Reason for Leaving:
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Education and Specialized Skills Information
School
Name/City/State
Major or
Course of Study
Last High
School
Attended
Did you
Graduate?
If yes, list
degree:
 Yes
 No
All Colleges
and
Universities
Attended
 Yes
 No
 Yes
 No
 Yes
 No
Other
Professional
Schools
(i.e.,
Advanced
Vocational,
Business,
Technical,
Secretarial,
etc.)
 Yes
 No
 Yes
 No
 Yes
 No
List any current certifications, licenses, technical and/or specialized skills applicable to the job for which you are applying:
References
Give the names of three business or professional references (please include at least one supervisor).
Name
Address
Telephone
Number/Email
Relationship
1.
2.
3.
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Years
Acquainted
In accordance with the Detroit City Code, applicants who reside in the City of Detroit, should not respond to the following question.
Have you ever been convicted of a crime (including any plea, verdict, or finding of guilt)?…………………….  Yes  No
If Yes*, please complete the following:
Where
Date
Explanation
Sentence
*Excluding arrests, please list any and all felony, misdemeanor and summary offense convictions (excluding traffic violations for $200 or less). A
criminal conviction will not automatically disqualify you from employment and job-related circumstances will be considered in determining suitability for
employment. However, failure to disclose a criminal conviction as required by the preceding inquiry may result in your disqualification for or
termination of your employment regardless of the nature of the conviction omitted.
For applicants in California, do not list (1) any conviction for which the record has been judicially ordered sealed, expunged, or statutorily eradicated; (2)
any record relating to a referral to, or participation in, a pre-trial or post-trial diversion program; (3) any convictions for marijuana offenses in violation of
Health and Safety Codes sections 11357(b) or (c), 11360 (c), 11364, 11365, or 11550, more than 2 years old; and (4) any misdemeanor conviction for
which probation was completed or otherwise discharged and the case was judicially dismissed. For applicants in the District of Columbia, do not list
any conviction or forfeiture of collateral that is more than 10 years old. For applicants in Georgia, do not list a criminal record that resulted in a deferred
adjudication. For applicants in Illinois, do not list a criminal record that has been expunged, sealed, or impounded.
Applicant Certification and Authorization
Certification of Application
I certify that any and all information contained in this Employment Application, and any and all information that I provide or
will provide to Vertex Inc. during the hiring process, including my resume, is accurate and complete. I understand and
agree that any misrepresentation, falsification, or omission of any information is grounds for disqualification from further
consideration for or termination of employment
AUTHORIZATION
I authorize all current and former employers, schools, persons, government agencies, and organizations having relevant
information or knowledge to provide it to Vertex Inc. for its use in deciding whether or not to offer me employment. I
release all employers, schools, persons, government agencies, and organizations from any liability, which may arise as a
result of responding to inquiries in connection with this Employment Application.
Employment at Will
I understand that nothing contained in this Employment Application, or in the granting of an interview, is intended to create
an employment contract between Vertex Inc. and me for either employment or for the provision of any other benefit. No
one, other than the President of the Company, has any authority to enter into any agreement for employment, or to make
any agreement contrary to the foregoing. If an employment relationship is established, I understand and agree that my
employment will be at-will which means that either Vertex Inc. or I may terminate the employment relationship, at any
time, with or without reason, and with or without prior notice.
Applicant Signature
Signature
Date*
*This Employment Application will remain active for one year from the above signed date.
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Notice and Authorization for Consumer Report
and Investigative Consumer Report
This Form, which you should read carefully, has been provided to you because Vertex Inc. may request consumer reports
or investigative consumer reports in connection with your application for employment, or at any time during the course of
your employment with Vertex Inc., if any, for purposes of evaluating your suitability for employment.
The types of reports that may be requested from consumer reporting agencies include, but are not limited to, credit
reports, criminal record checks, court records checks, driving records, and/or summaries of educational and employment
records and histories. The information contained in these reports may be obtained by a consumer reporting agency from
public record sources or through personal interviews with other individuals, and may include information about your
character, general reputation, personal characteristics, or mode of living. You have the right, upon written request to
Barbara Dyson, Vice President of Human Resources, Vertex Inc., to obtain a complete and accurate disclosure of the
nature and scope of any investigative consumer report prepared.
AUTHORIZATION
I have carefully read and understand this notice and authorize and consent to the release of consumer reports, as defined
above, to Vertex Inc. (1) in conjunction with my application for employment; and (2) during the entire course of my
employment, if any. I understand that the release of consumer reports to which I am consenting will be considered for
employment purposes.
____________________________________
Name (Printed)
Signature
Vertex Inc.
Date
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Pre-Offer Invitation to Self-Identify
Name:
Position Applying For:
Date:
Vertex Inc. (Vertex) is an Equal Opportunity Employer. Vertex does not discriminate on the basis of race, religion,
color, sex, age, non-disqualifying physical or mental disability, national origin, or any other basis covered by appropriate
law. All employment is decided on the basis of qualifications, merit, and business need.
Vertex is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights
laws and regulations. In order to comply with these laws, Vertex invites applicants to voluntarily self-identify their race or
ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse
treatment. The information obtained will be kept confidential and may only be used in accordance with the provisions of
applicable laws, executive orders, and regulations, including those that require the information to be summarized and
reported to the federal government for civil rights enforcement. When reported, data will not identify any specific
individual.
Check one:
_____ Male
_____ Female
Check one of the following Race/Ethnic Group:
_____
Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish
culture or origin regardless of race.
_____
White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle
East, or North Africa.
_____
Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups
of Africa.
_____
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the
peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
_____
Asian (Not Hispanic or Latino) - 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 Alaska Native (Not Hispanic or Latino) - 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 (Not Hispanic or Latino) – A person who identifies with more than one of the above five
races.
_____ I choose not to self-identify
Personal and Confidential
This page contains sensitive information, store in secure "Affirmative Action Forms" files, separately from
personnel records.
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