Staff Application Form

Name:*

First NameLast Name

E-mail Address:

example@example.com

Phone Number:*

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Birth Date*

MonthDayYear

Which position are you interested in? Check all that apply*

ProductionMaintenanceSanitationOther

What date are you available to start work?*

Date

Have you applied with the company before?*

YesNo

If "yes" give a date.

Have you worked for the company before?*

YesNo

If "yes" give a reason for leaving.

Do you have relatives that work for the company?*

YesNo

If "yes" please list them by name.

Are you a U.S. Citizen or an alien legally entitled to work in the position(s) for which you have applied?*

YesNo

Have you been convicted of a felony or misdemeanor (other than a minor traffic violation)? (Conviction will not necessarily disqualify applicant from employment)*

YesNo

If "yes" please explain.

Have you ever been discharged from any position?*

YesNo

If "yes" please explain.

What is your highest level of education completed?*

Grade schoolJunior High SchoolSenior High SchoolCollege

What is the name of the school?*

Number of years completed?*

Course pursued degrees granted*

Add your most recent job*

YesNo employment record

Employer / Company Name

Employer's Phone Number

Please enter a valid phone number.

Job title and duties

Starting Date

Date

Employment Ended

Date

Starting Salary

Final Salary

Reason for leaving

Please indicate that you have read and that you understand each paragraph of the Applicant's Statement by checking the box beside each paragraph.*

I certify that this application was completed by me and that all entries on it and all information on it are TRUE and COMPLETE to the best of my knowledge. In the event of employment, I understand that any false, misleading, inaccurate or omitted information in my application may result in discharge.I hereby release al parties, including but not limited to, the Company, its agents and employees, medical providers and previous employers, from any and all liability for any injury or damage, or claims thereof, resulting from furnishing any information to the Company concerning me or any action based on any such information.I agree to submit drug testing, if required, and understand that any offer of employment is contingent upon the results of that examination.I understand that, according to federal law, all individuals who are hired must, as a condition of employment, produce certain documentation to verify their identity and United States citizen status or, if aliens, their legal authorization to work in the United States. As a consequence, I understand that any offer of employment by the Company would be contingent upon my ability to produce the required documentation within the time period required by law.I understand that this application is not, and is not intended to be, a contract of employment and that any resulting employment relationship is for no fixed period of time and is terminable at any time and for any reason by the Company or by me. I further understand that statements which may be contained in policies, practices, handbooks, or other Company material do not create any guarantee of employment and the the Company has the right to modify, amend or terminate policies, practices, benefits plans, or other programs within the limits and requirements imposed by law. I understand that no representative of the Company has the authority to enter into any agreement for any specific period of time or to make any agreement contrary to the foregoing.

Signature*

635 Westfield Road • Noblesville • Indiana • 46060

Application for Employment

Employment Record

Applicant's Statement