Employment Application Print this formApplicant InformationFull Name First Last Date Address Street Address Apartment/Unit # City State Zip Code PhoneEmail Date Desired Salary $1st Shift or 2nd ShiftPosition 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: To Did you graduate Yes No Diploma:College:Address:From: to: Did you graduate Yes No Degree:Other:Address:From: To: Did you graduate Yes No Degree:Military ServiceBranchFrom: To: Rank at Discharge:Type of Discharge:If other than honorable, explain:Previous EmploymentCompanyPhoneAddress:Supervisor:Job Title:Starting Salary $Ending Salary $Responsibilities:From: To: Reson for Leaving:May we contact your previous supervisor for a reference? Yes No CompanyPhoneAddressSupervisor:Job Title:Starting Salary $Ending Salary $Responsibilities:From: To: Reason for Leaving:May we contact your previous supervisor for a reference? Yes No CompanyPhoneAddress:Supervisor:Job Title:Starting Salary $Ending Salary $Responsibilities:From: To: 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 Date of Birth:
