Employee Application

Employee Application
Position Applied For
Department Applied For*

CarbonAssemblyNanomeshQuality AssuranceMaintenanceInjection MoldingMachine ShopInventory, Shipping & ReceivingResearch & DevelopmentAdministrative SupportJanitorial
Shift Desired*

1st shift from 06:30 AM to 03:00 PM2nd shift from 03:00 PM to 11:30 PM3rd shift from 11:30 PM to 06:30 AM
Todays Date*

MonthDayYear
Date Available*

MonthDayYear
Referred By
Personal Information
Name*

First NameLast Name
Other Names By Which You Have Been Known
Social Security Number*
Home Phone
Phone Number*
Email*
May We Contact You At Work?*

YesNo
If Yes, Please Provide Work Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are You A U.S. Citizen?*

YesNo
If No, Are You Legally Authorized To Work In The U.S.?

YesNo
Please Note: Carbon Block Technology (CBTECH) participates in E-Verify.
Are You Able To Perform The Tasks For The Job You Are Applying?*

Without AccommodationWith Accommodation
Are You 18 or Older? If You Are Under 18 and Still In High School, You May Be Required To Provide A Work Permit.*

YesNo
As Part Of Our Standard Hiring Procedure, We Require All Candidates To Undergo Drug Testing and A Background Check. Are You Comfortable With This Requirement?*

YesNo
Have You Ever Been Committed Of A Crime Or Misdemeanor?*

YesNo
If Yes, Give Date, Place, Offense And Outcome
Names Of Friends Or Relatives Employed In The Organization
Were You Previously Employed By This Company?*

YesNo
If Yes, Dates Of Previous Employment.

MonthDayYear
MonthDayYear
Would You Work*

Full TimePart Time
Are You Able To Work Overtime?*

YesNo
Education
Indicate Last Level Completed

High SchoolCollege or UniversityGraduate School

Education 1
Name of School
City, State
Major
Did You Receive A Degree?

YesNo
Office Skills

TypingWord ProcessingSpreadsheetsData EntryMicrosoft Access
Other Skills
Additional Training, Education, Vocational, Professional, Military or Other Information You Feel May Be Helpful To Us In Considering Your Application

Employment 1
Employment History

(Please List Most Recent Employer First)

Employment 1
Company Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
May We Contact Employer?

YesNo
Employed From

MonthDayYear
Date
Employed To

MonthDayYear
Date
Job Title
Duties
Supervisor's Name & Title
Reason For Leaving
Starting Pay Rate
Ending Pay Rate

Employment 2
Company Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
May We Contact Employer?

YesNo
Employed From

MonthDayYear
Date
Employed To

MonthDayYear
Date
Job Title
Duties
Supervisor's Name & Title
Reason For Leaving
Starting Pay Rate
Ending Pay Rate

Employment 3
Company Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
May We Contact Employer?

YesNo
Employed From

MonthDayYear
Date
Employed To

MonthDayYear
Date
Job Title
Duties
Supervisor's Name & Title
Reason For Leaving
Starting Pay Rate
Ending Pay Rate

References

(1 Reference Required)

Reference 1
Name*
Phone Number*
Years Known*
Relationship*

Reference 2
Name
Phone Number
Years Known
Relationship

Reference 3
Name
Phone Number
Years Known
Relationship

Acknowledgment
I hereby certify that all of the statements I have made are true to the best of my knowledge and belief.
1. I understand that prior to finalization of any offer of employment, the company may condition the offer of employment on satisfactory completion of a medical examination and/or drug and alcohol screen. I agree to sign a release of medical information authorization form, and to submit to a medical examination and/or drug and alcohol screen should it be required.
2. I understand that my stated pre-employment qualifications are subject to investigation and I hereby authorize the company to investigate any and all information on this application.
3. I understand that neither the employment application nor any offer of employment are to be construed as a guarantee of employment for a specific time. I further understand that my employment with the organization does not constitute any form of contract, implied or express, and such employment will be terminable at will for any reason, either by myself or by employer, upon notice of one party to the other.
4. Except as required in the performance of my duties, I understand and agree that I will not, at any time during or after my employment, use, disclose or disseminate any confidential information or any other information of a secret, proprietary, or generally undisclosed nature. I agree to deliver to my employer any and all copies of confidential information, or other company property, upon termination of employment, or at any time upon my employer’s request.
5. I acknowledge that I have read and understand the above statement. The statements above supersede any prior statements made and set forth the complete agreement between me and CB Tech regarding these matters.
Signature*

Clear
Date*

MonthDayYear
Date
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