<?php
	if($mobile!='1'){session_start();}
	$company_name = "Demo Company";
?>


<div id="employment-application">


<h1><?php echo $company_name;?> Employment Application</h1>
<?php
if($_POST['submitted']){
	include('custom/thankyou.php');
}

if($ok!=1){

?>
<form action="employment" method="post" id="subForm">

<table cellspacing="3" cellpadding="4" border="0">

<tr valign="center">
<td align="left" valign="center" colspan=2><b>PERSONAL INFO: </b><hr></td>
<td></td>
</tr>
 
<tr valign="center">
<td align="right" valign="center">First Name: </td>
<td><input type="text" name="name" label="name" size="22" value="<?php echo $_POST['name'];?>"/></td>
</tr>

<tr valign="center">
<td align="right" valign="center">Middle Name: </td>
<td><input type="text" name="middle" label="middle" size="22" value="<?php echo $_POST['middle'];?>"/></td>
</tr>

<tr valign="center">
<td align="right" valign="center">Last Name: </td>
<td><input type="text" name="last" label="last" size="22" value="<?php echo $_POST['last'];?>"/></td>
</tr>


<div id="contact-email" style="display:none;">
<input type="text" name="cust-email" id="cust-email" size="22" value="<?php echo $_POST['cust-email'];?>"/>
</div>

<tr valign="center">
<td align="right" valign="center">Email address: </td>
<td><input type="text" name="email" id="email" size="22" value="<?php echo $_POST['email'];?>"/></td>
</tr>

<tr valign="center">
<td align="right" valign="center">Address: </td>
<td><input type="text" name="address" label="address" size="22" value="<?php echo $_POST['address'];?>"/></td>
</tr>

<tr valign="center">
<td align="right" valign="center">City: </td>
<td><input type="text" name="city" label="city" size="22" value="<?php echo $_POST['city'];?>"/></td>
</tr>

<tr valign="center">
<td align="right" valign="center">State: </td>
<td><input type="text" name="state" label="state" size="4" value="<?php echo $_POST['state'];?>"/></td>
</tr>
<tr valign="center">
<td align="right">Zip:  </td>
<td><input type="text" name="zip" label="zip" size="6"  value="<?php echo $_POST['zip'];?>"/></td>
</tr>

<tr valign="center">
  <td align="right" valign="center">Phone: </td>
  <td><input type="text" name="phone" id="phone" size="22" value="<?php echo $_POST['phone'];?>"/></td>
</tr>
<!--
<tr valign="center">
<td align="right" valign="center">Soc Sec#: </td>
<td><input type="text" name="socsec" label="socsec" size="22" value="<?php echo $_POST['socsec'];?>"/></td>
</tr>
-->
<tr>
  <td align="right" valign="center"><label for="Location">Are you 18 or older?: </label></td>
  <td>
  <select id="eighteen" name="eighteen">
<option value="">Make Selection</option>
<option value="no"<?php if($_POST['eighteen']=="no") {echo " selected='selected'";}?>>No</option>
<option value="yes"<?php if($_POST['eighteen']=="yes") {echo " selected='selected'";}?>>Yes</option>
</select></td>
</tr>

<tr>
  <td align="right" valign="center"><label for="Location">Do you have transportation?: </label></td>
  <td>
  <select id="transportation" name="transportation">
<option value="">Make Selection</option>
<option value="no"<?php if($_POST['transportation']=="no") {echo " selected='selected'";}?>>No</option>
<option value="yes"<?php if($_POST['transportation']=="yes") {echo " selected='selected'";}?>>Yes</option>
</select></td>
</tr>

<tr>
  <td align="right" valign="center"><label for="Location">Currently employed?: </label></td>
  <td>
  <select id="employed" name="employed">
<option value="">Make Selection</option>
<option value="no"<?php if($_POST['employed']=="no") {echo " selected='selected'";}?>>No</option>
<option value="yes"<?php if($_POST['employed']=="yes") {echo " selected='selected'";}?>>Yes</option>
</select></td>
</tr>

<tr valign="center">
<td align="right" valign="center">Date you can start: </td>
<td><input type="text" name="available_date" label="available_date" size="22" value="<?php echo $_POST['available_date'];?>"/></td>
</tr>

<tr>
  <td align="right" valign="center"><label for="Location">Desired Position: </label></td>
  <td>
  <select id="position" name="position">
<option value="">Make Selection</option>
<option value="cook"<?php if($_POST['position']=="cook") {echo " selected='selected'";}?>>Cook</option>
<option value="driver"<?php if($_POST['position']=="driver") {echo " selected='selected'";}?>>Driver</option>
<option value="manager"<?php if($_POST['position']=="manager") {echo " selected='selected'";}?>>Manager</option>
</select></td>
</tr>


<tr valign="center">
<td align="right" valign="center">Desired pay rate/salary: </td>
<td><input type="text" name="desired_pay" label="desired_pay" size="22" value="<?php echo $_POST['desired_pay'];?>"/></td>
</tr>

<tr valign="center">
<td align="right" valign="top" style="padding-top:6px;">Hours/days available: </td>
<td><textarea name="hours_available" label="hours_available" cols=23 rows=3><?php echo $_POST['hours_available'];?></textarea></td>
</tr>

<tr valign="center">
<td align="right" valign="center">Desired hours per week: </td>
<td><input type="text" name="hours_per_week" label="hours_per_week" size="22" value="<?php echo $_POST['hours_per_week'];?>"/></td>
</tr>

<tr><td colspan="2">&nbsp;</td></tr>

<tr>
  <td align="left" valign="center" colspan=2><label for="Location">Have you been convicted of a crime or had a diversion in the last 7 years?: </label></td>
  <tr>
	<td><td>
  <select id="convicted" name="convicted">
<option value="">Make Selection</option>
<option value="no"<?php if($_POST['convicted']=="no") {echo " selected='selected'";}?>>No</option>
<option value="yes"<?php if($_POST['convicted']=="yes") {echo " selected='selected'";}?>>Yes</option>
</select></td>
</tr>
<tr valign="center"><td></td>
<td align="left" valign="top" style="padding-top:6px;">If yes, nature of offense: <br />
<textarea name="offense" label="offense" cols=23 rows=3><?php echo $_POST['offense'];?></textarea></td>
</tr>

<tr><td colspan="2">&nbsp;</td></tr>

<tr>
  <td align="left" valign="center" colspan=2><label for="Location">Have you worked for <?php echo $company_name;?> before?: </label></td>
  <tr>
	<td><td>
  <select id="former_employee" name="former_employee">
<option value="">Make Selection</option>
<option value="no"<?php if($_POST['former_employee']=="no") {echo " selected='selected'";}?>>No</option>
<option value="yes"<?php if($_POST['former_employee']=="yes") {echo " selected='selected'";}?>>Yes</option>
</select></td>
</tr>
<tr valign="center"><td></td>
<td align="left" valign="top" style="padding-top:6px;">If yes, please list dates, location, supervisor and reason for leaving: </td>
</tr>
<tr><td><td><textarea name="former_detail" label="former_detail" cols=23 rows=3><?php echo $_POST['former_detail'];?></textarea></td>
</tr>

<tr><td colspan="2">&nbsp;</td></tr>

<tr valign="center">
<td align="left" valign="left" colspan=2><b>EDUCATION: </b><hr></td>
<td></td>
</tr>
<tr valign="center">
<td align="left" valign="top" colspan=2>High School: School name, city and grade completed: </td>
<tr><td><td><textarea name="high_school" label="high_school" cols=23 rows=3><?php echo $_POST['high_school'];?></textarea></td>
</tr>

<tr valign="center">
<td align="right" valign="center">Graduation Date: </td>
<td><input type="text" name="hs_grad_date" label="hs_grad_date" size="22" value="<?php echo $_POST['hs_grad_date'];?>"/></td>
</tr>

<tr><td colspan="2">&nbsp;</td></tr>

<tr valign="center">
<td align="left" valign="top" colspan=2>Current College: School name, city and grade completed: </td>
<tr><td><td><textarea name="college" label="college" cols=23 rows=3><?php echo $_POST['college'];?></textarea></td>
</tr>

<tr valign="center">
<td align="right" valign="center">Graduation Date: </td>
<td><input type="text" name="coll_grad_date" label="coll_grad_date" size="22" value="<?php echo $_POST['coll_grad_date'];?>"/></td>
</tr>

<tr><td colspan="2">&nbsp;</td></tr>

<tr valign="center">
<td align="right" valign="top" style="padding-top:6px;">School Achievements/Awards: </td>
<td><textarea name="achievements" label="achievements" cols=23 rows=3><?php echo $_POST['achievements'];?></textarea></td>
</tr>

<tr><td colspan="2">&nbsp;</td></tr>

<tr valign="center">
<td align="left" valign="left" colspan=2><b>OTHER: </b><hr></td>
<td></td>
</tr>

<tr valign="center">
<td align="left" valign="top" colspan=2>List any activities, hobbies or interests outside of work: </td>
<tr><td><td><textarea name="hobbies" label="hobbies" cols=23 rows=3><?php echo $_POST['hobbies'];?></textarea></td>
</tr>

<tr><td colspan="2">&nbsp;</td></tr>

<tr valign="center">
<td align="left" valign="left" colspan=2><b>DRIVER APPLICANTS: </b><hr>
<b>You must meet our Safe Driver Policy. Your MVR will be run prior to hiring and every 6 months.</b></td>
<td></td>
</tr>

<tr valign="center">
<td align="right" valign="center">Driver's License #: </td>
<td><input type="text" name="license" label="license" size="22" value="<?php echo $_POST['license'];?>"/></td>
</tr>

<tr valign="center">
<td align="right" valign="center">License State: </td>
<td><input type="text" name="license_state" label="license_state" size="22" value="<?php echo $_POST['license_state'];?>"/></td>
</tr>

<tr valign="center">
<td align="right" valign="center">License Expiration: </td>
<td><input type="text" name="license_date" label="license_date" size="22" value="<?php echo $_POST['license_date'];?>"/></td>
</tr>

<tr valign="center">
<td align="left" valign="top" colspan=2 style="padding-top:6px;">List any moving violations in the last 3 years (Dates & Descriptions): </td>
<tr><td><td><textarea name="driving_violations" label="driving_violations" cols=23 rows=3><?php echo $_POST['hobbies'];?></textarea>
</td>
</tr>
<tr><td align="left" valign="center" colspan="2" style="padding-top:8px;">In the last 5 years, have you been convicted of:</td></tr>
<tr>
  <td align="left" valign="center"><label for="leaving_scene">Leaving the scene of an accident: </label></td>
  <td>
  <select id="leaving_scene" name="leaving_scene">
<option value="">Make Selection</option>
<option value="no"<?php if($_POST['leaving_scene']=="no") {echo " selected='selected'";}?>>No</option>
<option value="yes"<?php if($_POST['leaving_scene']=="yes") {echo " selected='selected'";}?>>Yes</option>
</select></td>
</tr>
<tr>
  <td align="left" valign="center"><label for="Location">Illegal speeding contest: </label></td>
  <td>
  <select id="speed_contest" name="speed_contest">
<option value="">Make Selection</option>
<option value="no"<?php if($_POST['speed_contest']=="no") {echo " selected='selected'";}?>>No</option>
<option value="yes"<?php if($_POST['speed_contest']=="yes") {echo " selected='selected'";}?>>Yes</option>
</select></td>
</tr>
<tr>
  <td align="left" valign="center"><label for="Location">Reckless driving: </label></td>
  <td>
  <select id="reckless" name="reckless">
<option value="">Make Selection</option>
<option value="no"<?php if($_POST['reckless']=="no") {echo " selected='selected'";}?>>No</option>
<option value="yes"<?php if($_POST['reckless']=="yes") {echo " selected='selected'";}?>>Yes</option>
</select></td>
</tr>
<tr>
  <td align="left" valign="center"><label for="Location">Hit and run: </label></td>
  <td>
  <select id="hit_and_run" name="hit_and_run">
<option value="">Make Selection</option>
<option value="no"<?php if($_POST['hit_and_run']=="no") {echo " selected='selected'";}?>>No</option>
<option value="yes"<?php if($_POST['hit_and_run']=="yes") {echo " selected='selected'";}?>>Yes</option>
</select></td>
</tr>
<tr>
  <td align="left" valign="center"><label for="Location">DWI or DUI: </label></td>
  <td>
  <select id="dwi_dui" name="dwi_dui">
<option value="">Make Selection</option>
<option value="no"<?php if($_POST['dwi_dui']=="no") {echo " selected='selected'";}?>>No</option>
<option value="yes"<?php if($_POST['dwi_dui']=="yes") {echo " selected='selected'";}?>>Yes</option>
</select></td>
</tr>

<tr valign="center">
<td align="left" valign="center" colspan="2" style="padding-top:8px;">If you answered yes to any violations, please explain here: </td>
<tr><td><td><textarea name="violation_explanation" label="violation_explanation" cols=23 rows=3><?php echo $_POST['violation_explanation'];?></textarea>
</td>
</tr>

<tr valign="center">
<td align="right" valign="center">Insurance company: </td>
<td><input type="text" name="insurance_co" label="insurance_co" size="22" value="<?php echo $_POST['insurance_co'];?>"/> 
<tr><td align="right" valign="center">Policy #: <td><input type="text" name="policy_num" label="policy_num" size="22" value="<?php echo $_POST['policy_num'];?>"/></td>
</tr>

<tr valign="center">
<td align="right" valign="center">Policy effective dates: </td>
<td><input type="text" name="insurance_dates" label="insurance_dates" size="22" value="<?php echo $_POST['insurance_dates'];?>"/> 
<tr><td align="right" valign="center">Liability amount: <td><input type="text" name="liability" label="liability" size="22" value="<?php echo $_POST['liability'];?>"/>
</td>
</tr>

<tr><td colspan="2">&nbsp;</td></tr>

<tr valign="center">
<td align="left" valign="left" colspan=2><b>EMPLOYMENT HISTORY: </b><hr>
List 2 most recent positions held starting with most with recent employer first:</td>
<td></td>
</tr>

<tr><td colspan="2">&nbsp;</td></tr>

<tr valign="center">
<td align="left" valign="left" colspan=2><b><u>Most recent employer</u>: </b></td>
<td></td>
</tr>

<tr valign="center">
<td align="right" valign="center">Employer name: </td>
<td><input type="text" name="employer_1" label="employer_1" size="22" value="<?php echo $_POST['employer_1'];?>"/></td>
</tr>

<tr valign="center">
<td align="right" valign="center">Starting wage: </td>
<td><input type="text" name="emply1_start_wage" label="emply1_start_wage" size="10" value="<?php echo $_POST['emply1_start_wage'];?>"/></td>
</tr>
<tr valign="center">
<td align="right" valign="center">Ending wage: </td><td><input type="text" name="emply1_end_dt" label="emply1_end_dt" size="10" value="<?php echo $_POST['emply1_end_dt'];?>"/></td>
</tr>

<tr valign="center">
<td align="right" valign="center">Start date: </td>
<td><input type="text" name="emply1_start_dt" label="emply1_start_dt" size="10" value="<?php echo $_POST['emply1_start_dt'];?>"/></td>
</tr>
<tr valign="center">
<td align="right" valign="center">End date: </td><td><input type="text" name="emply1_end_wage" label="emply1_end_wage" size="10" value="<?php echo $_POST['emply1_end_wage'];?>"/></td>
</tr>


<tr valign="center">
<td align="right" valign="center">Reason for leaving: </td>
<td><input type="text" name="employ1_reason_left" label="employ1_reason_left" size="22" value="<?php echo $_POST['employ1_reason_left'];?>"/></td>
</tr>

<tr valign="center">
<td align="right" valign="center">Type of business: </td>
<td><input type="text" name="employer_1_bus" label="employer_1_bus" size="22" value="<?php echo $_POST['employer_1_bus'];?>"/></td>
</tr>


<tr valign="center">
<td align="right" valign="center">Position held: </td>
<td><input type="text" name="employer_1_position" label="employer_1_position" size="22" value="<?php echo $_POST['employer_1_position'];?>"/></td>
</tr>

<tr>
  <td align="right" valign="center"><label for="Location">Eligible for rehire?: </label></td>
  <td>
  <select id="emply1_rehire" name="emply1_rehire">
<option value="">Make Selection</option>
<option value="no"<?php if($_POST['emply1_rehire']=="no") {echo " selected='selected'";}?>>No</option>
<option value="yes"<?php if($_POST['emply1_rehire']=="yes") {echo " selected='selected'";}?>>Yes</option>
</select></td>
</tr>

<tr valign="center">
<td align="right" valign="center">Supervisor name: </td>
<td><input type="text" name="employer_1_supervisor" label="employer_1_supervisor" size="22" value="<?php echo $_POST['employer_1_supervisor'];?>"/></td>
</tr>

<tr valign="center">
<td align="right" valign="center">Employer phone: </td>
<td><input type="text" name="employer_1_phone" label="employer_1_phone" size="22" value="<?php echo $_POST['employer_1_phone'];?>"/></td>
</tr>

<tr>
  <td align="right" valign="center"><label for="Location">May we contact?: </label></td>
  <td>
  <select id="emply1_contact_ok" name="emply1_contact_ok">
<option value="">Make Selection</option>
<option value="no"<?php if($_POST['emply1_contact_ok']=="no") {echo " selected='selected'";}?>>No</option>
<option value="yes"<?php if($_POST['emply1_contact_ok']=="yes") {echo " selected='selected'";}?>>Yes</option>
</select></td>
</tr>


<tr valign="center">
<td align="left" valign="left" colspan=2><b><u>Previous employer</u>: </b></td>
<td></td>
</tr>

<tr valign="center">
<td align="right" valign="center">Employer name: </td>
<td><input type="text" name="employer_2" label="employer_2" size="22" value="<?php echo $_POST['employer_2'];?>"/></td>
</tr>

<tr valign="center">
<td align="right" valign="center">Starting wage:</td>
<td><input type="text" name="emply2_start_wage" label="emply2_start_wage" size="10" value="<?php echo $_POST['emply2_start_wage'];?>"/></td>
</tr>
<tr valign="center">
<td align="right" valign="center">Ending wage: </td><td><input type="text" name="emply2_end_wage" label="emply2_end_wage" size="10" value="<?php echo $_POST['emply2_end_wage'];?>"/></td>
</tr>

<tr valign="center">
<td align="right" valign="center">Start date: </td>
<td><input type="text" name="emply2_start_dt" label="emply2_start_dt" size="10" value="<?php echo $_POST['emply2_start_dt'];?>"/></td>
</tr>
<tr valign="center">
<td align="right" valign="center">End date: </td><td><input type="text" name="emply2_end_dt" label="emply2_end_dt" size="10" value="<?php echo $_POST['emply2_end_dt'];?>"/></td>
</tr>


<tr valign="center">
<td align="right" valign="center">Reason for leaving: </td>
<td><input type="text" name="employ2_reason_left" label="employ2_reason_left" size="22" value="<?php echo $_POST['employ2_reason_left'];?>"/></td>
</tr>

<tr valign="center">
<td align="right" valign="center">Type of business: </td>
<td><input type="text" name="employer_2_bus" label="employer_2_bus" size="22" value="<?php echo $_POST['employer_2_bus'];?>"/></td>
</tr>


<tr valign="center">
<td align="right" valign="center">Position held: </td>
<td><input type="text" name="employer_2_position" label="employer_2_position" size="22" value="<?php echo $_POST['employer_2_position'];?>"/></td>
</tr>

<tr>
  <td align="right" valign="center"><label for="Location">Eligible for rehire?: </label></td>
  <td>
  <select id="emply2_rehire" name="emply2_rehire">
<option value="">Make Selection</option>
<option value="no"<?php if($_POST['emply2_rehire']=="no") {echo " selected='selected'";}?>>No</option>
<option value="yes"<?php if($_POST['emply2_rehire']=="yes") {echo " selected='selected'";}?>>Yes</option>
</select></td>
</tr>

<tr valign="center">
<td align="right" valign="center">Supervisor name: </td>
<td><input type="text" name="employer_2_supervisor" label="employer_2_supervisor" size="22" value="<?php echo $_POST['employer_2_supervisor'];?>"/></td>
</tr>

<tr valign="center">
<td align="right" valign="center">Employer phone: </td>
<td><input type="text" name="employer_2_phone" label="employer_2_phone" size="22" value="<?php echo $_POST['employer_2_phone'];?>"/></td>
</tr>

<tr>
  <td align="right" valign="center"><label for="Location">May we contact?: </label></td>
  <td>
  <select id="emply2_contact_ok" name="emply2_contact_ok">
<option value="">Make Selection</option>
<option value="no"<?php if($_POST['emply2_contact_ok']=="no") {echo " selected='selected'";}?>>No</option>
<option value="yes"<?php if($_POST['emply2_contact_ok']=="yes") {echo " selected='selected'";}?>>Yes</option>
</select></td>
</tr>


<tr valign="top">
<td colspan=2><br><hr><br>
Please be sure you have filled out the application completely in order to ensure timely processing. 
<br><br>
</tr><tr><td colspan=2>
<?php
echo'<center><img src="captcha/captcha.php" id="captcha" /><br/>
		<!-- CHANGE TEXT LINK -->
		<a href="#" onclick="
		document.getElementById(\'captcha\').src=\'captcha/captcha.php?\'+Math.random();
		document.getElementById(\'captcha-form\').focus();"
		id="change-image">Not readable? Change text.</a><br/><br/>
		<p><strong>Type the letters from the image above:</strong></p>
		<input type="text" name="captcha" id="captcha-form" /><br/></center>';
?>
</td></tr>
<tr valign="top">
<td align="center" colspan="2"><input name ="submitted" type="submit" value="Submit Application" /></td>
</tr>
</table>
</form>
<?php
}

?>
<script type="text/javascript">  

 var frmvalidator  = new Validator("subForm");  //use the name/id of your form in the parenthesis
 
frmvalidator.addValidation("name","req","Please enter your name");  
frmvalidator.addValidation("last","maxlen=20", "Max length is 20");  
 frmvalidator.addValidation("email","maxlen=50");  
 frmvalidator.addValidation("email","req");  
 frmvalidator.addValidation("email","email");  
 frmvalidator.addValidation("phone","maxlen=50");  
 //frmvalidator.addValidation("time","req"); 
</script>


</div>

