Manufacturing Employment Application

It is the policy of PQM and SHD to provide equal employment opportunities to all applicants and employees without regard to any legally protected status such as race, color, religion, geder, national origin, age, disability, veteran status or any other legally protected status.

Applicant Name*

First NameMiddle NameLast Name

Current Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry

Number of Years at this Address*

Social Security Number*

Email Address*

Phone Number*

Area CodePhone Number

About this Phone Number (select all that apply)*

Home PhoneCell PhoneSend/Receive TxtAvailable in Daytime

Who referred you to complete this application?

Are you at least 18 years old?*

YesNo

Driver License Number:*

What state issued your license?*

Have you ever been convicted of a crime, excluding minor traffic violations?*

YesNo

If Yes, please describe:

	Date	Offense	Felony Degree	Mesdemeanor Degree	Comments/Description	Dates of Incarceration
1:
2:
3:

THE EXISTENCE OF A CRIMINAL RECORD DOES NOT CONSTITUTE AN AUTOMATIC BAR TO EMPLOYMENT UNLESS RELEVANT TO THE TYPE OF EMPLOYMENT.

Are you eligible to work in the United States?*

YesNo

Have you applied to our company previously?*

YesNo

If Yes, when?

Available start date, if offered employment:

MonthDayYear

Position Applied for:*

Are you able to perform the essential functions of the job position with or without reasonable accommodation?*

YesNo

Current/Most Recent Employer:*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Job Duties:*

Date Started at Current/Most Recent Employer:

Date Ended with Most Recent Employer:

Rate of Pay:

Reason for Leaving:

May we contact your Current/Most Recent Employer?

YesNoOther

Previous Employer 1:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Job Duties:

Date Started at Previous Employer 1:

Date Ended at Previous Employer 1:

Rate of Pay:

Reason for Leaving:

Previous Employer 2:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Job Duties

Date Started at Previous Employer 2:

Date

Date Ended at Previous Employer 2:

Date

Rate of Pay

Reason for Leaving

Other Relevant Employment Positions held:

High School attending/ed:

City/State:

Number of years attended:

Year Graduating/ed:

College attending/ed:

City/State:

Number of years attended:

Did you receive a degree?

YesNo

Area of Study/Degree:

Other Education, Skills, Qualifications:

(Graduate, technical, vocational)

Awards, Honors, Special Achievements:

List your skills that may be useful for the job you are seeking:

I'm looking for:

Part Time Hours (15-29 hours per week)Full Time Hours (30-40 hours per week)Full Time, plus overtime when availableSeasonal

Work Availability:

	Early Shift	Mid-day shift	Overnight Shift
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Reference 1:*

First NameLast Name

Reference 1 Phone:

Area CodePhone Number

Reference 1 Email:

example@example.com

Reference 1 Relationship:

Reference 2:

First NameLast Name

Reference 2 Phone:

Area CodePhone Number

Reference 2 Email:

example@example.com

Reference 2 Relationship:

Please provide any other information you feel should be considered:

Upload Resume

Upload a File

CERTIFICATION & RELEASE

All qualified applicants will receive consideration without discrimination based on gender (male/female), marital status, race, color, age, creed, national origin, sexual orientation, military reserve membership, veterans’ status, ancestry, religion, height, weight, disability, or any other legally protected status.

I understand that consideration for employment depends upon the results of a criminal background check and present/previous employment checks, and reference check. I therefore, authorize PQM and SHD to thoroughly investigate my background, references, work history, education, and other matters related to my suitability for employment and further authorize the references listed to disclose to PQM and SHD any and all letters, faxes, reports, and other information related to my education and work records, without giving me prior notice of such disclosure.

I understand PQM and SHD is committed to an alcohol/drug free workplace and, as permitted by law, I am required to take a drug test as part of the selection and hiring process and also understand that random drug testing will be conducted during my employment.

I understand that nothing in this application is intended to imply or create employment relationship or contract for employment. I understand that if I am hired my employment will be “at will” for no definite period of time. I understand that I have the right to terminate my employment at anytime and for any reason with or without notice, and that PQM and SHD has the same right.

By signing below, I certify that the information included on this application is true and correct to the best of my knowledge. I understand that any false statements on the application or during the interview process and/or missing information may disqualify me from employment or justify my dismissal if employed.

I HAVE CAREFULLY READ THE ABOVE CERTIFICATION & RELEASE. I UNDERSTAND AND AGREE TO ITS TERMS.

YesNo

Signature

Manufacturing Employment Application

Applicant Employment History

Applicant Education and Training

References