LEV INC. EMPLOYMENT FORM

Full Name

First NameMiddle NameLast Name

Other Names which you have attended school or been employed:

First NameMiddle NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Social Security #

Home Phone Number

Work Phone Number

Cell Phone Number

Birth Date

MonthDayYear

Are you eligible to work in the United States?

YesNo

Are you 18 years of age or older?

YesNo

Are you currently employed?

YesNo

Have you ever been employed by Louisville Exchanger?

YesNo

Are you related to any current Louisville Exchanger employee?

YesNo

If required for position, do you have a valid driver's license?

YesNo

How did you learn about this employment oppurtunity? (Check all that apply)

Expected Salary ($)

Date You Can Start

Date

High School

Name of High School Attended

Number of Years Attended

Graduated with GED?

YesNo

College

Name of College/University Attended

City/State

Area of Study/Degree

Number of Years Attended

Graduated?

YesNo

Date of Graduation if YES

Number of Years left if NO

Degree Received if YES

Trade School/Other

Name of Trade/Technical/Other School Attended

City/State

Area of Study/Degree

Number of Years Attended

Graduated?

YesNo

Date of Graduation if YES

Number of Years left if NO

Degree Received if YES

Other Credentials / Licenses / Professional Affiliations / etc., which are relevant to the job(s) for which you are applying:

Please list Technical skills, clerical skills, trade skills, etc., relevant to this position. Include relevant computer systems and software packages of which you have a working knowledge, and your level of proficiency (basic, intermediate, expert).

List any relevant skills

Previous Employer

Name of Previous Employer

Employer Address

Position

Part-Time / Full-Time

If PART-TIME, # of hours per week

Start Date

Date

End Date

Date

Starting Salary ($)

Finishing Salary ($)

Primary Duties?

Reason for Leaving?

Supervisor's Name, Ttile, Phone #

Contact my Reference:

At any timeIf only I am a finalist canadate

Previous Employer

Name of Previous Employer

Employer Address

Position

Part-Time / Full-Time

If PART-TIME, # of hours per week

Start Date

Date

End Date

Date

Starting Salary ($)

Finishing Salary ($)

Primary Duties?

Reason for Leaving?

Supervisor's Name, Ttile, Phone #

Contact my Reference:

At any timeIf only I am a finalist canadate

Previous Employer

Name of Previous Employer

Employer Address

Position

Part-Time / Full-Time

If PART-TIME, # of hours per week

Start Date

Date

End Date

Date

Starting Salary ($)

Finishing Salary ($)

Primary Duties?

Reason for Leaving?

Supervisor's Name, Ttile, Phone #

Contact my Reference:

At any timeIf only I am a finalist canadate

Reference 1

Name of Reference

Address (if known)

Phone Number

Please enter a valid phone number.

Years Acquainted

Reference 2

Name of Reference

Address (if known)

Phone Number

Please enter a valid phone number.

Years Acquainted

Reference 3

Name of Reference

Address (if known)

Phone Number

Please enter a valid phone number.

Years Acquainted

PLEASE READ CAREFULLY AND SIGN THAT YOU UNDERSTAND AND ACCEPT THIS INFORMATION.

I certify that the information on this application and its supporting documents is accurate and complete. I understand and agree that failure to fully complete the form, or misrepresentation or omission of facts, represents grounds for elimination from consideration of employment, or termination after employment if discovered at a later date. I authorize Louisville Exchanger & Vessel Inc. to investigate, without liability, all statements contained in this application and supporting materials. I authorize references and former employers, without liability, to make full responses to any inquiries in connection with this application for employment, if requested, I agree to submit to a physical exam, criminal and credit background investigation, and/or screening for illegal substances upon conditional offer of employment. I understand this document is NOT an offer of employment, and that an offer of employment, if tendered, does NOT constitute a contract for continued guaranteed employment. I understand that staff employees of Louisville Exchanger & Vessel Inc. serve at-will, and will be required to furnish proof of eligibility to work in the United States, to file a State security questionnaire and State loyalty oath, and to comply with company and departmental regulations. I understand that I would be required to make mandatory contributes to the Louisville Exchanger & Vessel, Inc. Retirement System or to an optional retirement program, if applicable. I understand that any benefits I receive may be subjected to change or discontinue at any time without prior notice. I understand that the first SIX MONTHS of regular employment represent a provisional period, during which I would not be eligible to apply for transfer or promotion and during which I may be terminated without right of appeal.

Signature

Date

APPLICATION FOR EMPLOYMENT

Personal Information:

Employment Desired:

Education:

Skills/Qualifications:

Work Experience / Previous Employment:

References:

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