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Information Company

Location:
Chippewa Falls, Wisconsin, 54729, United States
Posted:
August 28, 2017

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EMPLOYMENT APPLICATION

INSTRUCTIONS

If you need help to fill out this application form or for any phase of the employment process, please notify the person that gave you this form and every effort will be made to accommodate your needs in a reasonable amount of time. 1. Please thoroughly read all statements contained in this Application form. 2. Complete all pages of this form completely and accurately. 3. Print clearly. Incomplete or illegible applications will not be processed. 4. Do not fill out any other attached forms unless and until instructed. This application applies only to the position specified. It is considered inactive after 60 days. If at any time after this point you wish to be considered for employment, another application will have to be completed. EEO STATEMENT

We are an Equal Employment Opportunity employer, and do not discriminate in our hiring or employment practices. All qualified applicants will receive consideration without regard to race, color, creed, religion, national origin, citizenship, age, disability, sex, military service, genetic testing, ancestry, order of protection status, marital status, sexual orientation, or any other characteristic protected by Local, State or Federal law.

APPLICANT INFORMATION

Position Applied For: Date:

Name: Email:

(First) (M.I.) (Last)

Home Phone: Mobile Phone: Home Address:

(Street)

(City) (State) (Zip)

Have you ever worked for Brabazon Pumpe and Compressor Co., Ltd. or Pure-Aire before? Yes No If “Yes,” why did you leave?

If “Yes,” under what name, if different: Approx. Dates: Location: Position: Supervisor:

AVAILABILITY

Are you legally authorized to work in the United States? Yes No Are you under the age of 18? Yes No If “Yes”, can you provide proof of eligibility to work? Yes No On what date can you start?

What job category would you prefer? Full-time Part-time Wage Expected? $ Hourly Annual For what schedules would you be available? Weekdays Weekends Days Evenings Overtime

All Shifts Other

EDUCATION

Please check highest grade completed: 7 8 9 10 11 12 13 14 15 16 16+ Name of High School: City/State:

Graduate? Yes No Graduate with: High School Diploma GED Name of College: City/State:

Graduate? Yes No If “Yes,” Degree:

Additional Education/Certifications/License/Training: Name of School: City/State:

Graduate? Yes No If “Yes,” Degree:

Other:

JOB-RELATED SKILLS

Have you received a job description or had the requirements of the job explained to you? Yes No Do you understand these requirements? Yes No

Can you perform the requirements of this job with or without reasonable accommodation? Yes No If the job requires you to drive, do you have the appropriate valid driver's license? Yes No DL# Type State of Issue

Have you had any moving violations? Yes No

If “Yes,” please describe and include date of incident(s): Please list your computer skills:

Please list any other skills and or experience that may be job-related or that you feel would be of value to this job or our organization:

PROFESSIONAL REFERENCES

Name Company Title Phone Relationship

1.

2.

3.

EMPLOYMENT HISTORY

MOST RECENT EMPLOYER

Are you currently working for this employer? Yes No If yes, may we contact your current employer? Yes No Company Name City State Phone Number

From (month/yr): To (month/yr):

Dates Employed Supervisor's Name/Number

$ Hourly Annually

Job Title Pay

Duties

Reasons for Leaving

SECOND MOST RECENT EMPLOYER Company Name City State Phone Number

From (month/yr): To (month/yr):

Dates Employed Supervisor's Name/Number

$ Hourly Annually

Job Title Pay

Duties

Reasons for Leaving

THIRD MOST RECENT EMPLOYER Company Name City State Phone Number

From (month/yr): To (month/yr):

Dates Employed Supervisor's Name/Number

$ Hourly Annually

Job Title Pay

Duties

Reasons for Leaving

CERTIFICATION

I certify that the information that I have provided to the Company as part of this application along with any resume or other material submitted by me for employment consideration is true, complete and without omissions or misleading statements. I understand that my employment may be terminated because of false, misleading or omitted information, regardless of the time that may have elapsed between furnishing the information and the discovery by the Company. I authorize the Company to inquire into my education, professional and past employment history with references as needed to determine my qualifications and suitability for employment. I hereby give my consent to any former employer or educational institution to provide academic or employment related information about me to the Company. This includes any pertinent information they may have, personal or otherwise and I release all parties from all liability for any damage that may result from furnishing this information. I understand that I may be required to pass a pre-employment drug test and that my Social Security number must be validated. I further acknowledge that certain positions with the Company may also require a confirmation that I am licensed to drive a motor vehicle, and that my credit, civil and criminal records may be checked including a verification of my address. I consent freely and voluntarily to participate in the required drug test and background checks and consent to the release of the results to the Company. I hereby release and hold harmless the Company from any liability whatsoever arising from the drug test and/or background checks and decisions concerning employment based upon the results of these tests and checks.

I understand that nothing in this employment application, the granting of an interview or possible subsequent employment offer is intended to create an employment contract between myself and the Company. If hired, I will be an

“Employee At-Will” which means the Company may release me at any time for any reason with or without cause, and I am likewise free to leave at any time for any reason. I understand that no representative of the Company other than the President or Chief Executive Officer has any authority to enter into any agreement for employment that contradicts or modifies the foregoing in any manner, and any such agreement must be in writing and signed by the President or Chief Executive Officer.

If hired, I agree to conform to rules, regulations and policies which the Company may periodically issue, withdraw, or modify. If hired, I understand that I will be required to keep my hair color within the range of “natural” colors (no blue, green, or other non-natural hair colors are allowed) and that facial piercings are not appropriate. I also understand that in order to comply with Company policy any visible tattoos will need to be covered appropriately during the work day, if hired. I agree to follow the Company grooming guidelines and to be dressed appropriately per the standards of the Company at all times in the workplace, if I am hired. A photocopy, digital, and/or electronic copy of this signed authorization is as effective and binding as the original. Signed: Date:

Print Name: _

First Name MI Last Name



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