Employment Application Form Page 2
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1
2Employer
From
Position/Job Description
Specific Reason for Leaving
Address
To
Supervisor
Total Years
Telephone
Employer
From
Position/Job Description
Specific Reason for Leaving
Address
To
Supervisor
Total Years
Telephone
Employer
From
Position/Job Description
Specific Reason for Leaving
Address
To
Supervisor
Total Years
Telephone
Non-Administrative Applicants – The type of work required in the factory will require the applicant
______ Yes ______No
from time to time to lift up to forty (40) pounds. Can you perform that task? If no, Please explain.
________________________________________________________________________________________
Do you have any limitations on your ability to perform the job classification for which you are
______ Yes ______No
applying? If yes, describe the limitations.
______Yes ______No
If necessary, would you be willing to work second shift?
______________________________________________________________________________________
Date you can begin work
_____Yes
_____No
______Yes ______No
Are you presently employed?
If so, may we contact your present employer?
I hereby swear that the above information is true and correct to the best of my knowledge and I understand that any omission or
misrepresentation of a material fact in this application may result in my termination. I hereby authorize the company to make any
investigation of my background deemed necessary. I have no objection to signing an employee arbitration agreement or an agreement on
confidential information and inventions, or taking a job-related physical examination, or disclosing any information, which may affect my
job performance.
I agree to submit to an alcohol and /or drug test for marijuana, cocaine, opiates, phencyclidine (PCP), and
amphetamines as part of my application for employment and to release these tests results to the company. I fully understand that either a
positive test result or refusal to submit to the drug testing procedure may disqualify me from further consideration from employment. By
signing below, I agree that any employment offered is on an “at will” basis. Employment may be terminated with or without cause, at
anytime for any reason.
______________________________________________________
______________________________________________________
Signature of Applicant
Date of Signature
TO BE FILLED IN BY INTERVIEWER
Interviewed by___________________________________________ Date_______________________________ Time_____________________
Results of
Interview_____________________________________________________________________________________________________________
RF 279 REV. A
11/8/2017
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Parent category: Business