Employment Application Print this formApplicant InformationFull Name First Last Date MM slash DD slash YYYY Address Street Address Apartment/Unit # City State Zip Code PhoneEmail Date MM slash DD slash YYYY Desired Salary $1st Shift or 2nd Shift Position Applied for: Are you a citizen of the United States Yes No If no, are you authorized to work in the U.S.? Yes No 1.1.6 Immigration Law Compliance All offers of employment are contingent on verification of your right to work in the United States. On your first day of work, you will be asked to provide original documents verifying your right to work and, as required by federal law, to sign Federal Form I-9, Employment Eligibility Verification Form. If you at any time cannot verify your right to work in the United States, FillTech USA, LLC may be obliged to terminate your employment. Have you ever worked for this company? Yes No If yes, when? Have you ever been convicted of a felony? Yes No If yes, explain: EducationHigh School: Address: From: MM slash DD slash YYYY To MM slash DD slash YYYY Did you graduate Yes No Diploma: College: Address: From: MM slash DD slash YYYY to: MM slash DD slash YYYY Did you graduate Yes No Degree: Other: Address: From: MM slash DD slash YYYY To: MM slash DD slash YYYY Did you graduate Yes No Degree: Military ServiceBranch From: MM slash DD slash YYYY To: MM slash DD slash YYYY Rank at Discharge: Type of Discharge: If other than honorable, explain: Previous EmploymentCompany PhoneAddress: Supervisor: Job Title: Starting Salary $Ending Salary $Responsibilities: From: MM slash DD slash YYYY To: MM slash DD slash YYYY Reson for Leaving: May we contact your previous supervisor for a reference? Yes No Company PhoneAddress Supervisor: Job Title: Starting Salary $Ending Salary $Responsibilities: From: MM slash DD slash YYYY To: MM slash DD slash YYYY Reason for Leaving: May we contact your previous supervisor for a reference? Yes No Company PhoneAddress: Supervisor: Job Title: Starting Salary $Ending Salary $Responsibilities: From: MM slash DD slash YYYY To: MM slash DD slash YYYY Reason for Leaving: May we contact your previous supervisor for a reference? Yes No Disclaimer and SignatureI certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. Signature on this application is your written consent for pre-employment background check. Signature: Date MM slash DD slash YYYY Date of Birth: MM slash DD slash YYYY
