Lenoir Mirror Company

Lenoir Mirror Company
Application For Employment
It is our policy to comply with all applicable state and federal laws prohibiting discrimination in employment based on race, age, color, sex, religion, national origin, disability or other protected classifications.

Please carefully read and answer all questions. You will not be considered for employment if you fail to completely answer all the questions on this application. You may attach a résumé, but all questions must be answered.
PERSONAL DATA
Name (last, first, middle)*
Desired Position*
Date Of Birth*

MonthDayYear
Date
Address*

Street Address and/or Mailing Address

Street Address Line 2

CityState

Zip
Do you have a High School Diploma or GED?*

YESNO
Home Telephone Number
Format: (000) 000-0000.
Business/Daytime Number*
Format: (000) 000-0000.
Date you can start work*
Cellular Phone Number
Format: (000) 000-0000.
Previously Employed with Lenoir Mirror Comp.?*

YESNO
Are you authorized to work in the U.S. on an unrestricted basis?*

YESNO
Have you ever been convicted of a felony? (Convictions will not necessarily disqualify an applicant for employment.) Yes*
Have you ever been convicted of a felony? (Convictions will not necessarily disqualify an applicant for employment.)*

YESNO
Have you been told the essential functions of the job or have you been viewed a copy of the job description listing the essential functions of the job?*

YESNO
Can you perform these essential functions of the job with or without reasonable accommodation? YES*
Can you perform these essential functions of the job with or without reasonable accommodation?*

YESNO

College/University*

Rows	School Name	Degree	Address/City/State
High School
College/University
Other

SPECIAL SKILLS List any special skills or experience that you feel would help you in the position that you are applying for leadership, organizations/teams, etc.

REFERENCES Please list three professional references not related to you, with full name, address, phone number, and relationship. If you don’t have three professional references, then list personal, unrelated references.

Rows	Name	Address/City/State	Phone	Relationship

Work History
Job Title #1
Start Date (mo/day/yr)

MonthDayYear
Date
End Date (mo/day/yr)

MonthDayYear
Date
Company Name
Supervisor’s Name
City
State
Phone Number
Format: (000) 000-0000.
Zip
Duties
Reason for Leaving
Starting Salary
Ending Salary
May we contact your present/previous employer?

YESNON/A
Job Title #2
Start Date (mo/day/yr)

MonthDayYear
Date
End Date (mo/day/yr)

MonthDayYear
Date
Company Name
Supervisor’s Name
City
State
Phone Number
Format: (000) 000-0000.
Zip
Duties
Reason for Leaving
Starting Salary
Ending Salary
Job Title #3
Start Date (mo/day/yr)

MonthDayYear
Date
End Date (mo/day/yr)

MonthDayYear
Date
Company Name
Supervisor’s Name
City
State
Phone Number
Format: (000) 000-0000.
Zip
Duties
Reason for Leaving
Starting Salary
Ending Salary
Job Title #4
Start Date (mo/day/yr)

MonthDayYear
Date
End Date (mo/day/yr)

MonthDayYear
Date
Company Name
Supervisor’s Name
City
State
Phone Number
Format: (000) 000-0000.
Zip
Duties
Reason for Leaving
Starting Salary
Ending Salary
I certify that the facts set forth in this Application for Employment are true and complete to the best of my knowledge. I understand that if I am employed, false statements, omissions or misrepresentations may result in my dismissal. I authorize the Employer to make an investigation of any of the facts set forth in this application and release the Employer from any liability. The employer may contact any listed references on this application.
I acknowledge and understand that the company is an “at will” employer. Therefore, any employee (regular, temporary, or other type of category employee) may resign at any time, just as the employer may terminate the employment relationship with any employee at any time, with or without cause, with or without notice to the other party.*
Date*

MonthDayYear
Date
Should be Empty:

Lenoir Mirror Company

Application For Employment

PERSONAL DATA

Work History