Employment Application

Print Name Date

Last First Middle

All applicants will receive consideration for employment without regard to race, color, sex, national origin, religion, age, marital status, physical or mental disability, veteran status, or any other prohibited criterion. Barb & Plank Company offers equal employment opportunity and treatment to all employees and applicants for employment.

Position(s) applied for

(You must specify the position(s) you are applying for. Applications containing indefinite responses, such as “any available position” will not be considered). Applicants will remain valid for 60 days, after which you should reapply if you are still interested in a position with our company.

Phone Other Phone Social Sec. No.

Where you can be located

Present address

No. Street City State Zip

Previous address

No. Street City State Zip

Do you have adequate transportation to work? Yes No

Do you have any relatives working for this company? Yes No

Does your immigration status permit you to accept employment lawfully, immediately, and indefinitely? Yes No

If not, what must be done in order for you to accept or continue the proposed employment lawfully?

Have you ever been bonded? Yes No If yes, on what jobs?

Have you been convicted of, or pled guilty, no contest to, or received deferred adjudication for a felony or misdemeanor?

Yes No If yes, describe in full (use additional paper if necessary):

(A conviction, plea of guilty or no contest, or deferral is not an automatic bar to employment; all circumstances will be considered.)

Record of Previous Employment

Present Employer

(or most recent) Kind of Business

Address City State & Zip Phone

Starting date Starting title Starting earnings

Present date Present title Present earnings

Starting duties

Present duties

Last immediate supervisor’s name and title

What did you like BEST about this job?

What did you like LEAST about this job?

Reason for leaving

May we contact your present employer now without jeopardizing your position?

Previous Employer Kind of Business

Address

City State & Zip Phone Starting date Starting title Starting earnings

Leaving date Leaving title Leaving earnings

Starting duties

Leaving duties

Last immediate supervisor’s name and title

What did you like BEST about this job?

What did you like LEAST about this job?

Reason for leaving

Previous Employer Kind of Business

Address

City State & Zip Phone

Starting date Starting title Starting earnings

Leaving date Leaving title Leaving earnings

Starting duties

Leaving duties

Last immediate supervisor’s name and title

What did you like BEST about this job?

What did you like LEAST about this job?

Reason for leaving

If more than three previous employers, list others here:

Dates From To

Company and Address

Position or Type of Work

Salary or Wage

Reason for Leaving

-

-

-

Please explain fully any gaps in your employment history.

What special skills & qualifications do you have?

What machines or equipment can you operate?

Educational Record

School

Date

Name of School

City

Major Course or Subject

Did you graduate?

High School

College or University

From To

Night School

Business College

Correspondence School

Other

References

(Not employers or relatives -- At least three)

Name Phone

Address Occupation

Name Phone

Address Occupation

Name Phone

Address Occupation

Occasionally the form of an application makes it difficult for an individual to adequately summarize his/her complete background. To assist us in finding the proper position for you in our company, use the space below to summarize any additional information necessary to describe your full qualifications.

PLEASE READ CAREFULLY BEFORE SIGNING

Applicant’s Certification and Agreement

I hereby certify that the information I have provided on this application (and any other document I have provided) is true, correct, and complete. I understand that any falsification, misrepresentation or omission in this application or hiring process will be sufficient grounds for rejection of the application or termination of employment without notice at any time hereafter. I understand that, as part of the pre-employment process, an investigative consumer report may be obtained by the company, including information as to my character, general reputation, personal characteristics and mode of living. Upon my written request, within a reasonable time from the date of this application, additional information as to the nature and scope of the investigation and report, if any, will be provided. I hereby release all persons furnishing information in connection with the investigative consumer report from liability or damages incurred as a result of such an inquiry and furnishing of this information.

I herby authorize any and all schools, former employers, references, courts, and any others who have information about me to provide such information to the company and/or any of its representatives, agents, or vendors, and I release all parties involved from any and all liability for any and all damage that may result from providing such information.

I understand that if offered a position, I will be required to submit to a pre-employment health survey, which may include drug screening. I understand that unsatisfactory results from, refusal to cooperate with, or any attempt to affect the results of these pre-employments tests and checks will result in withdrawal of any employment offer or termination of employment if already employed.

In consideration for employment by the company, if employed, I agree to conform to the rules, regulations, policies and procedures of the company at all times and understand that such obedience is a condition of employment.

If employed, I understand that I retain my normal right to terminate any employment relationship at any time, with or without any notice or reason, and I understand that the company retains the same right. I also recognize that nothing shall alter the terminable-at-will nature of my employment relationship with the company unless it is in writing and signed by the president of the company.

I agree that in consideration of my employment with the Company that if I file a lawsuit regarding the conditions of my employment or termination of employment, I will waive my right to a jury trial and that no demand, request or motion will be made for trial by jury. Instead, I agree that the case will be tried to a judge without a jury.

BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ABOVE STATEMENTS.

Applicant’s Signature

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