Application Form

Please complete all fields below.

Applicant Name(Required)

Position Applied For(Required)

Preferred Work Location(Required)

Phone(Required)

Alternate Phone

Present Address(Required)

City(Required)

State(Required)

Zip

(Optional)

Date of Birth(Required)

Social Security Number(Required)

If under the age of 18, can you produce the necessary work certificate at the time of employment?(Required)

Yes

N/A

Type of employment desired?(Required)

Full-time

Part-time

Seasonal

Other

If Other – Specify Hours

Are you willing to work overtime?(Required)

Yes

Date on which you can start work, if hired:(Required)

If hired, can you provide proof that you are legally eligible for employment in the U.S.?(Required)

Yes

(Pursuant to the Immigration Reform and Control Act of 1986, all applicants (U.S. and non-U.S.) who are offered employment must produce documents establishing their identity and authorization for U.S. work no later than seventy-two (72) business hours after employment begins. All new hires will be required to verify their employment authorization under oath by signing INS Form 1-9 upon commencing employment.)

Have you previously applied for employment with this Company?(Required)

Yes

When and where did you apply?

Have you ever been employed by this Company?(Required)

Yes

Provide dates of employment, location, and reason for separation from employment.

Do you have any commitments to any other employer which could affect your employment with this Company if hired (for example, an employment agreement, a non-competition, or non-solicitation agreement, etc.)?(Required)

Yes

Please explain and provide a copy:

Level of Education (Check All That Apply)

High School

College

Graduate / Professional

Trade or Correspondence

High School

School Name & Location

(Address, City, State)

Course of Study or Major

Graduate?

Yes

Honors Received

College

School Name & Location

(Address, City, State)

Course of Study or Major

Graduate?

Yes

Number of Years Completed

Honors Received

Graduate / Professional

School Name & Location

(Address, City, State)

Course of Study or Major

Graduate?

Yes

Number of Years Completed

Honors Received

Trade / Correspondence

School Name & Location

(Address, City, State)

Course of Study or Major

Graduate?

Yes

Number of Years Completed

Honors Received

WORK EXPERIENCE

Please list the names of your present and/or previous employers in chronological order with present or most recent employer listed first. Provide information for at least the most recent ten (10) year period. Attach additional sheets if needed. If selfemployed, supply firm name and business references. You may include any verifiable work performed on a volunteer basis or internships. You may describe any training or work experience received in any U.S. military service. Your failure to completely respond to each inquiry may disqualify you for consideration from employment. Do not answer “see résumé.”

Employer Name

Employer Address

Type of Business

Phone

Dates Employed

From xx/xx/xxxx – To xx/xx/xxxx

Job Title

Supervisor's Name

Duties

May we contact

Yes

Reason why we cannot contact?

Reason for leaving?

Were you terminated?

Yes

What will this employer say was the reason your employment terminated?

Were you ever disciplined? If so, for what?

If you resigned, how much notice did you give? If none, explain

Work Experience – Employer 2

Employer Name

Employer Address

Type of Business

Phone

Dates Employed

From xx/xx/xxxx – To xx/xx/xxxx

Job Title

Supervisor's Name

Duties

May we contact

Yes

Reason why we cannot contact?

Reason for leaving?

Were you terminated?

Yes

What will this employer say was the reason your employment terminated?

Were you ever disciplined? If so, for what?

If you resigned, how much notice did you give? If none, explain

Upload Resume

Drop files here or

Max. file size: 50 MB.

Have you ever been terminated or asked to resign from any job?

Yes

Have you ever been given the choice to resign rather than be terminated?

Yes

If you answered yes to either of the above two questions, please explain the circumstances of each occasion.

Briefly describe any special skills, training, or experience you possess relevant to the position for which you are applying:

List any professional or occupational registration, licensure or certification you currently hold which is relevant to the position for which you are applying and/or indicate whether you have ever had any related professional registration, license, or certification suspended, revoked or terminated:

References

Please list the names of additional work-related references we may contact who have worked with you in the past. Individuals with no prior work experience may list school or volunteer-related references.

Reference 1

Position

Company

Work Relationship

Telephone / Email

Reference 2

Position

Company

Work Relationship

Telephone / Email

Please Answer All Questions. Résumés Are Not A Substitute For A Completed Application.

We are an equal opportunity employer. Applicants are considered for positions without regard to veteran/military status, race, color, religion, sex/gender, national origin, ancestry, age, disability, genetic information, pregnancy (including childbirth, lactation, and related medical conditions), alienage or citizenship status, sexual orientation, gender identity or expression, or any other category protected by applicable federal, state, or local laws.

THIS APPLICATION FOR EMPLOYMENT IS NOT AN EMPLOYMENT CONTRACT.

The Company provides reasonable accommodations to applicants with disabilities to assist in the hiring process, as required by applicable federal, state, and local law. Individuals can request an accommodation to complete this application or to participate in the interview process by contacting Human Resources.

APPLICANT CERTIFICATION

I understand and agree that if driving is a requirement of the job for which I am applying, my employment and/or continued employment is contingent on possessing a valid driver’s license for the state in which I reside and automobile liability insurance in an amount equal to the minimum required by the state where I reside.

I understand that the Company may now have, or may establish, a drug-free workplace or drug and/or alcohol testing program consistent with applicable federal, state, and local law. If the Company has such a program and I am offered a conditional offer of employment, I understand that if a pre-employment (post-offer) unlawful drug and/or alcohol test is positive, the employment offer may be withdrawn where allowed by law. I agree to work under the conditions requiring a drug-free workplace, consistent with applicable federal, state, and local law. I also understand that all employees of the location, pursuant to the Company’s policy and federal, state, and local law, may be subject to urinalysis or other medically recognized tests designed to detect the presence of alcohol or illegal or controlled drugs. If employed, I understand that alcohol and/or drug testing may be a condition of continual employment and I agree to undergo alcohol and drug testing consistent with the Company’s policies and applicable federal, state, and local law.

If employed by the Company, I understand and agree that the Company, to the extent permitted by federal, state, and local law, may exercise its right, without prior warning or notice, to conduct investigations of Company property (including, but not limited to, files, lockers, desks, vehicles, and computers) and, in certain circumstances, my personal property. I UNDERSTAND THAT I HAVE NO EXPECTATION OF PRIVACY IN COMPANY PROPERTY.

I understand and agree that as a condition of employment and to the extent permitted by federal, state, and local law, I may be required to sign a confidentiality, restrictive covenant, and/or conflict of interest statement.

I certify that all the information on this application, my résumé, or any supporting documents I may present during any interview is and will be true, complete and accurate, to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of any information may result in disqualification from further consideration for employment or, if employed, disciplinary action, up to and including immediate dismissal, regardless of when such information is discovered

The Company considers this Application for Employment to be a part of the personnel record

THIS COMPANY IS AN AT-WILL EMPLOYER WHERE ALLOWED BY APPLICABLE STATE LAW. THIS MEANS THAT REGARDLESS OF ANY PROVISION IN THIS APPLICATION, IF HIRED, THE COMPANY OR I MAY TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, FOR ANY REASON, WITH OR WITHOUT CAUSE OR NOTICE. NOTHING IN THIS APPLICATION OR IN ANY DOCUMENT OR STATEMENT, WRITTEN OR ORAL, SHALL LIMIT THE RIGHT TO TERMINATE EMPLOYMENT AT-WILL. I UNDERSTAND THAT NO COMPANY EMPLOYEE OR REPRESENTATIVE HAS THE AUTHORITY TO ENTER INTO A CONTRACT REGARDING DURATION OF TERMS AND CONDITIONS OF EMPLOYMENT OTHER THAN THE PRESIDENT/CEO OF THE COMPANY AND THEN ONLY BY MEANS OF A WRITTEN CONTRACT SIGNED BY THE PRESIDENT/CEO.

I authorize the Company and/or its agents to confirm all statements contained in this application and/or résumé as it relates to the position I am seeking, to the extent permitted by federal, state, or local law. Federal law and some states require a separate disclosure and consent when obtaining background reports from a consumer reporting agency. I understand I will be asked to complete any requisite consent forms for the background check which may be required by federal, state and/or local law. I agree to sign these forms and understand that my offer of employment may be conditional upon the background check.

I AUTHORIZE AND CONSENT TO, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY THIS EMPLOYER (INCLUDING ANY AND ALL PRIOR EMPLOYERS OF MINE) TO FURNISH INFORMATION REGARDING MY PREVIOUS EMPLOYMENT HISTORY AND/OR ANY OF THE ABOVE-MENTIONED INFORMATION. I hereby release, discharge, and hold harmless, to the extent permitted by federal, state, and local law, any party delivering information to the Company pursuant to this authorization from any liability, claims, charges, or causes of action which I may have as a result of the delivery or disclosure of the above requested information. I hereby release from liability the Company for seeking such information and all other persons, corporations, or organizations furnishing such information.

If hired by the Company, I understand that I will be required to provide genuine documentation establishing my identity and eligibility to be legally employed in the United States by this Company as required by the Immigration Reform and Control Act of 1986. I also understand this Company employs only individuals who are legally eligible to work in the United States.

FLORIDA APPLICANTS

I understand that, in accordance with Florida Statute § 443.131(3)(a)(2), if hired, I will be placed on a 90- day probationary period. I further understand that if I am terminated for unsatisfactory work performance within the 90-day probationary period, the Company may seek to contest any employment benefit I might attempt to obtain as a result of my termination.

To the extent required by applicable law, the Company maintains a smoke-free workplace.

I CERTIFY THAT ALL OF THE INFORMATION THAT I HAVE PROVIDED ON THIS APPLICATION IS TRUE, ACCURATE, AND COMPLETE.

DO NOT SIGN UNTIL YOU HAVE READ ALL OF THE INFORMATION CONTAINED IN THE APPLICATION.

Applicant Signature(Required)

Date(Required)

Is Applicant a Minor?(Required)

Yes

Parent / Legal Guardian Name

Parent / Legal Guardian Signature

Please complete all fields below.

High School

College

Graduate / Professional

Trade / Correspondence

WORK EXPERIENCE

Work Experience – Employer 2

References

Please Answer All Questions. Résumés Are Not A Substitute For A Completed Application.

THIS APPLICATION FOR EMPLOYMENT IS NOT AN EMPLOYMENT CONTRACT.

APPLICANT CERTIFICATION

FLORIDA APPLICANTS

Riley Gear

Florida-Headquarters

New York - Plant

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