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Application for Employment

    PERSONAL INFORMATION

    NameSocial Security Number
    AddressCityStateZip Code
    TelephoneEmailReferred by

    EMPLOYMENT DESIRED

    Position SoughtDate AvailableSalary Desired
    Are you Employed: YesNoIf so, may we contact your current employer? YesNo
    Have You Applied to Mechanical Rubber Before?YesNo If so, when?

    EDUCATION HISTORY

    Name & Location of School
    # Years
    Graduated?
    Year Graduated
    Grammar SchoolYesNo
    High SchoolYesNo
    College / Trade SchoolYesNo
    Course Study

    GENERAL INFORMATION

    Special Skills / Expertise :
    Military Service:

    EMPLOYMENT HISTORY

    Position 1 (most recent)

    Start Date
    End Date
    Name & Address of Employer
    Salary
    Position
    Reason for Leaving
    Responsibilities:Accountabilities:

    Position 2

    Start Date
    End Date
    Name & Address of Employer
    Salary
    Position
    Reason for Leaving
    Responsibilities:Accountabilities:

    Position 3

    Start Date
    End Date
    Name & Address of Employer
    Salary
    Position
    Reason for Leaving
    Responsibilities:Accountabilities:

    Position 4

    Start Date
    End Date
    Name & Address of Employer
    Salary
    Position
    Reason for Leaving
    Responsibilities:Accountabilities:

    REFERENCES

    Name
    Address
    Phone
    Business
    Years Known

    Comments

    Upload Resume if available (not required)

    AUTHORIZATION

    "I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.
    I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.
    I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.
    This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws."

    Date:Signature:
    You will be required to sign this form in person, should you be called in for an interview.

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