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Job Application

Job Application

Apply for a job at Centerra with this convenient form.

Step 1 of 5

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PERSONAL & EMPLOYMENT DATA
Today's Date*
MM slash DD slash YYYY
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email
Are you 18yrs. of age?*
- YES
- NO
Some positions involve the use of heavy equipment or dangerous chemicals and, therefore, persons under the age of 18 are not eligible for those positions.
Do you have a legal right to permanently live and work in the U.S.?*
- YES
- NO
Position or type of work desired?
- Regular
- Temporary
- Full Time
- Part Time
Date Available
Position/Job Desired*

The more specific you can be the better. Example: "Ravenna Retail Manager", or "fuel transport driver". If unsure, write "UNSURE".
Salary Desired
How were you referred to us?
- Newspaper
- Agency
- School
- Centerra Employee
- Other
How did you find out about a position at Centerra?
Name of Referral or Source

Please list the name(s) of the person or organization that referred you to Centerra.

EDUCATION & PROFESSIONAL HISTORY
High School

List the Name, City and State of your high school.
Years Attended

List the years you attended this school. (e.g. "2015-2019")
Graduated?*
- YES
- NO
*Grade Completed

If you did not graduate, what is the highest grade level completed?
*Certificate or Diploma?
- YES
- NO
If you did not graduate from high school, do you have an equivalency diploma or certificate?
College

List the Name, City and State of your College. (If multiple, list most recent first.)
Years Attended

List the years you attended this school. (e.g. "2015-2019")
Graduated?
- YES
- NO
Grade/Hours Completed
Degree/Curriculum
College (1)

List the Name, City and State of your College. (If multiple, list most recent first.)
Years Attended

List the years you attended this school. (e.g. "2015-2019")
Graduated?
- YES
- NO
Grade/Hours Completed
Degree/Curriculum
College (2)

List the Name, City and State of your College. (If multiple, list most recent first.)
Years Attended

List the years you attended this school. (e.g. "2015-2019")
Graduated?
- YES
- NO
Grade/Hours Completed
Degree/Curriculum
Other Training

List the name, city and state of any other training facilities or educational institutions you have attended.
Years Attended

List the years you attended this school. (e.g. "2015-2019")
Graduated/Certified?
- YES
- NO
Type of Degree or Certification

List the certificates or diplomas received during this other training.
Professional Licenses and Certifications
Professional Organizations

List any affiliations with or memberships to professional organizations.

REFERENCES
List three people other than relatives who know of your qualifications for the position(s) for which you are applying. For each reference, provide a working phone number and/or email address, list the nature of your professional relationship (Advisor, Supervisor, etc.) and the number of years you've known the reference.
Reference 1 Name
Reference 1 Phone
Reference 1 Email Address
Reference 1 Professional Relationship
Reference 1 Years Known
Please enter a number from 0 to 99.
Reference 2 Name
Reference 2 Phone
Reference 2 Email Address
Reference 2 Professional Relationship
Reference 2 Years Known
Please enter a number from 0 to 99.
Reference 3 Name
Reference 3 Phone
Reference 3 Email Address
Reference 3 Professional Relationship
Reference 3 Years Known
Please enter a number from 0 to 99.

EMPLOYMENT HISTORY
List current or most recent employment first.
May we contact your current employer?
- YES
- NO
Firm Name (1)
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Job Title
Starting Date

Month and Year
Ending Date

Month and Year (Write PRESENT if still employed here.)
Ending (or Current) Salary
Supervisor's Name
Reason for Leaving
Duties
Firm Name (2)
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Job Title
Starting Date

Month and Year
Ending Date

Month and Year (Write PRESENT if still employed here.)
Starting Salary
Ending (or Current) Salary
Supervisor's Name
Reason for Leaving
Duties
Firm Name (3)
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Job Title
Starting Date

Month and Year
Ending Date

Month and Year (Write PRESENT if still employed here.)
Starting Salary
Ending (or Current) Salary
Supervisor's Name
Reason for Leaving
Duties
Signature Required*
I understand that if I am selected for employment, such employment will be for an indefinable period and may be terminated at any time by either party in accordance with the rules and regulations governing terminations "at will". I certify that the forgoing answers are correct to the best of my knowledge and belief.
EQUAL OPPORTUNITY EMPLOYER
Signature Required*
You have my permission to obtain information pertaining to my character, integrity, dependability and ability from the references and employers who are listed above and those employers are hereby authorized to release information.
Consent*
This digital document and the digital signatures contained herein are to be considered original for all purposes for which this document may be used.

IMPORTANT NOTICE: REGARDING BACKGROUND REPORTS
In connection with your application for employment, Centerra Co-Op Inc. may obtain one or more reports regarding your consumer credit, criminal records, driving record, education, prior employer verification, workers compensation claims and other public record information from a consumer reporting agency. If Centerra Co-Op Inc. uses any information it obtains from a background report in a decision to not hire you or to make any other adverse employment decision regarding you, Centerra Co-Op Inc. will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon a background report, Centerra Co-Op Inc. will notify you that the action has been taken and that the background report was the reason for the action. We cannot obtain such background reports regarding you unless you consent in writing. If you do not agree that we may obtain background reports regarding your background history, please sign below.
For Identification and Research Purposes Only:
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Other (Former) Names
Social Security Number
Driver's License State
Driver's License Number
Date of Birth
MM slash DD slash YYYY
Gender
Signature
I have read the above Notice Regarding Background Reports provided to me by Centerra Co-Op Inc. and I understand that is I sign this consent form, Centerra Co-Op Inc. may obtain reports of my background history. I hereby authorize Centerra Co-Op Inc. and its employees, agents, and affiliates to obtain reports of my background history as described above.
Today's Date
MM slash DD slash YYYY
Consent*
This digital document and the digital signatures contained herein are to be considered original for all purposes for which this document may be used.
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