THIS COMPANY IS AN EQUAL OPPORTUNITY EMPLOYER

PLEASE ANSWER ALL QUESTIONS COMPLETELY AND ACCURATELY
   
Name:  
  (Last) (First) (Middle)  
         
Address:
  (Number & St) (City) (State) (Zip Code)
   
E-mail:
   
Telephone: Cell Phone:  
   
Previous Address:
  (Number & St) (City) (State) (Zip Code)
   
Wage/Salary Desired: $ /Hr
 
Hours Desired:   Full Time    Part Time   Summer Student
 
Are you available for manufacturing positions?   Yes No
*MANUFACTURING POSITIONS REQUIRE ROTATING SWING SHIFTS
 
Identify relevent skills or training you have or equipment you can operate:
 
Have you been employed or applied for employment with this company before? Yes No
Have you ever applied for a position with this company before? Yes No
 
Are you over age 18?   Yes No
   
What position are you applying for? 
   
Were you referred here? How? 
   
List names of any friends or relatives who work for the Company:
Name: Relationship: 
Name: Relationship: 
   
Personal References  
Name Address Telephone:
1.

Occupation / Relationship to you /  
     
2.

Occupation / Relationship to you /  
     
3.
Occupation / Relationship to you /  
     
 
Education
  Institution Name Address Years Complete Degree
High School: 10 11  12
College: 1 2   3   4
Graduate Work: 1 2   3   4
Other: 1 2   3   4
 
Only US Citizens or aliens who have a legal right to work in the US are eligible for employment. Can you, upon employment, submit documentation of your identity and your legal right to work in the US?   Yes No
 
Employment History: List all Position held starting with the most recent. Use Additional Boxes if needed
 
Employer 1
 
  (Name) (Address) (Telephone)
 
  (Duties) (Title) (Supervisor)
  to  per 
  (Dates of Employment) (Salary)
 
  (Reason for Leaving)
Employer 2
 
  (Name) (Address) (Telephone)
 
  (Duties) (Title) (Supervisor)
  to  per 
  (Dates of Employment) (Salary)
 
  (Reason for Leaving)
Employer 3
 
  (Name) (Address) (Telephone)
 
  (Duties) (Title) (Supervisor)
  to  per 
  (Dates of Employment) (Salary)
 
  (Reason for Leaving)
Employer 4
 
  (Name) (Address) (Telephone)
 
  (Duties) (Title) (Supervisor)
  to  per 
  (Dates of Employment) (Salary)
 
  (Reason for Leaving)
 

Have you ever been convicted of a crime, other than a minor traffic violation, had adjudication withheld, or pled no contest to a crime?  
Yes No

If YES, please state the type of crime and the circumstances with regard to each, including date of the conviction or pleas and the penalty, if any, imposed by the court.

NOTE: Answering YES to any of these questions may not necessarily disqualify you from the position you desire. Each action and explanation will be weighted/considered in relationship to the position for which you are applying.

 
 

AFFIRMATIVE ACTION FORM
Government Agencies require reports on status of applicants. This data is for analysis and affirmative action only. Submission is voluntary. Failure to supply this information will not jeopardize or adversely affect any consideration you may receive for employment, or later advancement in employment.



Gender: Male Female  
 

Race/Ethnicity:

American Indian or Alaskan Native - a person having origins of any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment
 
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
 
Black or African American - A person having origins in any of the Black racial groups of Africa. Terms such as “Haitian” or “Negro” can be used in addition to “Black or African American”.
 
Native Hawaiian or Other Pacific Islander - A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
 
White - A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.
 
Hispanic or Latino (All races) - A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.
 
Hispanic or Latino (White Race Only) - A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, and of the White race.
 
Hispanic or Latino (All Other Races) - A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, and any race other than White.
 
Race Missing or Unknown - Applies to Applicants only, where a resume or application that is screened is received without any racial or ethnic identification and no further contact is made with the applicant.
    
Veteran: Yes   No
 
 

Confirmation Area

 

I attest to the truthfulness of any and all information and answers provided above. Any false or misleading statements will be grounds for denial of employment or discharge. I understand the company will be checking into my references and employment background. I authorize the Company to do so and release from liability anyone giving or obtaining such background information. This application does not constitute a contract of employment or an indication that any jobs are available. Any employment with the Company is at­will, meaning the employer or employee can end the employment relationship at any time for any or no reason and with or without notice. My signature below verifies that I have read and understand the foregoing statements.

I Agree to the Terms and Conditions Above.

 
 
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Today's Date 12/18/2017

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