Kem-Tec Employment Application

The following information is requested in order to help us make the best possible placement within the Company. All portions of this application pertaining to you must be completed. We appreciate the time your spend in filling in this application. Applications submitted incomplete will not be considered for hire. The Company, in accordance with state and federal laws, does not discriminate on the basis of age, race, religion, color, sex, height, weight, national origin, physical or mental handicap, or any other legally protected status.

Full Name*

Present Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Home Telephone Number*

Alternate Telephone Number

Are you under 18 years of age?*

YesNo

Social Security Number*

Have you ever filed an application with or previously and been employed with this Company?*

YesNo

If so, when and where?

If related to anyone in our employment, please provide name and relationship

How did you learn about this job?*

Have you ever been known by another name? If yes, what name?

Are you a U.S. citizen or are you otherwise eligible to work in the U.S.? (Proof of U.S. citizenship or immigration status will be required upon employment)*

YesNo

Position you are applying for*

Employment type*

Full timePart timeTemporary

Yearly salary or hourly rate desired*

Date you can start*

Date

This job for which you are applying may require work on Saturdays, Sundays and holidays. While reasonable accommodation can be made for you, are you willing to work such a schedule?*

YesNo

If NO, briefly explain:

Can you travel?*

YesNo

Are you employed now?*

YesNo

If YES, may we contact your current employer?

YesNo

Are you on lay off and subject to recall?*

YesNo

Do you have a valid auto operator's license?*

YesNo

If YES, please provide State and Number

Has your operator's license ever been suspended, revoked or restricted?*

YesNo

Have you ever been convicted of a crime?*

YesNo

If YES, describe when, where and the nature of the offense

If there are any felony charges pending against you, please explain when, where and the nature of the charges

Were you in the armed forces?*

YesNo

If YES, what branch and rank at discharge

Describe any job related military training

Record of Education

High School or Prep School*

Location*

Major Subject*

Number of years*

Diploma*

YesNo

College or University

Location

Major Subject

Number of years

Degree

Graduate School

Location

Major Subject

Number of years

Degree

Other-including Military services, Trade, or Business School

Location

Number of years

Certificate

Experience:

Business or Professional Record of Last Three Positions

(List order starting with most recent employer)

From*

Date

To

Company Name*

Position*

Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Supervisor*

Reason for separation*

Yearly Salary or Hourly Rate*

From*

Date

To*

Date

Company Name*

Position*

Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Supervisor*

Reason for separation*

Yearly Salary or Hourly Rate*

From*

Date

To*

Date

Company Name*

Position*

Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Supervisor*

Reason for separation*

Yearly Salary or Hourly Rate*

References:

List the names and telephone numbers of three (3) personal/business references, who are not related to you.

Full Name*

Phone Number*

Years Known*

Full Name*

Phone Number*

Years Known*

Full Name*

Phone Number*

Years Known*

Narrative: Please write a brief summary of the reasons why you have sought employment with us.*

Special Employment Notice

If an offer of employment is make for a certain job classification, a medical examination may be required before beginning employment duties.

Michigan Law prohibits discrimination in employment based on handicap. Beginning June 25, 1990, an applicant or employee requirement accommodation for employment must notify the employer in writing withing 182 days after the need is known.

Acknowledgement and Certification

I acknowledge that consideration for employment may be contingent on the results of a reference and background check. Therefore, I authorize the Company to: (1) Investigate the truthfulness of all statements made on this application; (2) Contact my former employers and other listed references or any other persons who can verify information; (3) Discuss results of any investigation with other employees of the Company involved in the hiring process. In addition, I give consent for all contacted persons, including former employers, to provide information to the Company.

I further acknowledge and understand that employment may be contingent on a motor vehicle records check; I therefore authorize the Company to obtain such information.

All applicants who are conditionally considered for employment may, as a final step in the employment process, be required to submit to a physical examination and/or the drug screen test. If the application refuses to consent to the physical examination or the drug screen, the applicant will be denied employment. If the applicant tests positive, the applicant will be denied employment.

I further acknowledge that, should I be hired by the Company, my employment will be, "at will", that the terms of my employment and compensation can be terminated with or without cause and with or without notice at any time at the option of either the employer or myself.

I certify that the information contained in this application is correct to the best of my knowledge and understand that falsification of this application in any detail is grounds for disqualification from further consideration or for dismissal from employment in accordance with Company policy. I agree to conform to the rules and regulations of the Company. I further understand that no personnel recruiter or interviewer or any other representative of the Company, has any authority to enter into a contract of employment except for the Company president or president's designate, and such agreement shall be signed by both the Company and the employee.

Please attach your resume *

Signature*

Date*

Date

Pre-Employment Questionnaire

Complete ONLY if you are applying for field, delivery or sales positions.

By signing this document you understand that due to Company insurance policy, anyone with 4 points or more on his/her motor vehicle record is uninsurable and therefore unsuitable for operating a company vehicle. Company procedure requires that a motor vehicle report be acquired for all applicants in this category.

Have you had any tickets or automobile accidents in the last 5 years? If YES, please explain

Have you ever had your driver's license suspended or revoked for any reason? If YES, please explain

Complete only if you are applying for an office position.

How many WPM are you able to type?

Signature

Date