Last, First, Middle
Street, City, State, Zip
Phone *
Phone
Are you 18 years or older? *
Are you either a U.S. Citizen or an alien authorized to work in the United States? *
Are you presently employed? *
Per hour
Previously employed here? *
Phone *
Phone
Address
Address
Education
The Age Discrimination in Employment Act of 1967 prohibits discrimination the basis of age with respect to individuals who are at least 40 but less than 70 years of age.
Have you served an apprenticeship? *
All qualified applicants will receive consideration without regard to age, race, color, religion, sex, national origin, handicap, or military status. ABILITY TO PERFORM ESSENTIAL REQUIREMENTS OF THE JOB I have been shown a written description of the job I have applied for and the essential requirements of that job have been demonstrated to me. Based upon the written description and observation of the demonstration, the Applicant states that he/she: (check the appropriate box) *
references: give the names of three persons not related to you, whom you have known for at least one year.
Reference 1 *
Reference 1
Phone *
Phone
Address
Address
Reference 2 *
Reference 2
Phone *
Phone
Address
Address
Reference 3 *
Reference 3
Phone *
Phone
Address
Address
emploYMENT HISTORY: Give Names and Addresses of 3 Previous or manufacturing related Employers.
Contact
Contact
Phone
Phone
Date of employment end
Date of employment end
Contact
Contact
Phone
Phone
Date of employment end
Date of employment end
Contact
Contact
Phone
Phone
Date of employment end
Date of employment end
I agree that any false statement in this application shall be sufficient cause for rejection or dismissal. I hereby grant permission to investigate any of the information included in this application and to submit to medical examination if required. The use of this form does not indicate there are any position open and does not in any way obligate this Company. Safety devices and equipment shall be used as a condition of employment.
Witness *
Witness
Applicant Signature (Your name entered here represents your signature on this application.) *
Applicant Signature (Your name entered here represents your signature on this application.)

This form has been designed to strictly comply with State and Federal fair employment practice laws prohibiting discrimination on the basis of an applicant's sex or minority status. Questions directly or indirectly reflecting such status have been included only where needed to determine a bona fide occupational qualifica tion or for other permissible purposes. Such questions are appropriately noted on the application.