Hafendorfer Machine, Inc. | Employment Application

Last Name:

First Name:

Middle Initial:

Current Address:

County:

City:

State:

Zip Code:

How long at this address?

Home telephone number including area code:

Cell phone #:

E-mail address:

Date available for work:

Position applying for:

Are you willing to work overtime?

YES NO

Are you applying for:

Desired Shift?

Salary desired:

Do you own a reliable car that can get you to and from work everyday?

YES NO

In case of emergency, contact (complete name, telephone number and relationship):

Do you have a valid driver’s license?

YES NO

Driver’s License Number:

Exp. Date:

State of Issue:

EDUCATION (highest grade completed):

High School:

College:

Degree(s) Earned:

Trade, Business or Correspondence School:

U.S. Military or Naval Service (include rank):

Have you ever been convicted of or been on probation or deferred adjudication for or are you now awaiting trial for, on probation for, or on deferred adjudication for any felony or misdemeanor?

YES NO

If answered yes, please explain all convictions (include dates):

Have you at any time in the past worked for Jungle Jim’s or Hafendorfer Machine?

YES NO

If answered yes, please provide dates of employment & reason for leaving:

Are you legally eligible for employment in this country:

YES NO

Are you able to read, write, and speak fluent English?

YES NO

Are you currently unemployed?

YES NO

If Yes, please tell us how long you have been unemployed:

(Please list your current, as well as, your 3 previous employers, starting with the most recent. Please do not leave any information blank.)

Current Employer:

From - To Dates

Company Name

Address

Phone #

Immediate Supervisor

Position

Pay Rate $

Job Duties

Reason for Leaving

Previous Employer:

From - To Dates

Company Name

Address

Phone #

Immediate Supervisor

Position

Pay Rate $

Job Duties

Reason for Leaving

Previous Employer:

From - To Dates

Company Name

Address

Phone #

Immediate Supervisor

Position

Pay Rate $

Job Duties

Reason for Leaving

Previous Employer:

From - To Dates

Company Name

Address

Phone #

Immediate Supervisor

Position

Pay Rate $

Job Duties

Reason for Leaving

Pease explain any time gaps in your employment history:

May we contact your current or previous employers for an employment reference?

YES NO

Please list any work experience or special skills that you feel might be relevant to your employment here.

I understand that false or inaccurate information in this Application will be a basis for termination from employment, denial of workers' compensation benefits, and/or unemployment compensation benefits. I authorize the Company to investigate my background and verify this information. I further authorize the Company to release the information contained in this Application to its customers, insurance company representatives, and/or legal counsel.

I understand and agree that I will be employed at-will by the Company. I understand that this means that either the Company or I may terminate my employment at any time for any or no reason. I have reviewed and understand this Application and I agree to follow the policies and procedures set forth in this Application. I understand that nothing in this Application alters or changes my employment-at-will status. I also recognize that the Company, at its sole discretion, may add to, revoke, or modify the policies, practices and procedures contained in this Application.

I, hereby declare that all statements contained in this Application are true and accurate.

Application Date

PERSONAL INFORMATION:

PRESENT & FORMER EMPLOYER(S):

WORK EXPERIENCE & SKILLS:

CERTIFICATION