APPLICATION FOR EMPLOYMENT

Please make sure you fill in all of the fields correctly.

PERSONAL

Last Name: First: Middle: Today's Date: MM/DD/YYYY
Street Address: Home Telephone: ###-###-####
City: State: Zip: Business Telephone: ###-###-####
Have you ever applied for employment with us? Y N
If Yes: Month and Year MM/YY 		Social Security Number: ###-##-####
Position Desired: Pay Expected:
Are you able to report to work in the assigned position, regardless of shift? Y N Are you able to work overtime if asked? Y N
Are you legally eligible for employment in the United States? Y N Date available to work: MM/DD/YYYY
Have you been convicted of a felony in the last seven (7) years? Y N
If yes, please explain: 		If under 18, can you furnish a work permit? Y N

Why do you want to work for Jackson Tube Service?

NOTE: PROSPECTIVE EMPLOYEES WILL RECEIVE CONSIDERATION WITHOUT DISCRIMINATION
BECAUSE OF RACE, CREED, COLOR, AGE, NATIONAL ORIGIN, HANDICAP, OR VETERAN STATUS.

EUCATIONAL BACKGROUND

School Name & Location Course of study Did you graduate? Degree or Diploma
High School Y N Degree Diploma
College Y N Degree Diploma
Apprentice, Business, Technical, Vocational, or Military School Y N Degree Diploma

Summarize special skills and qualifications acquired from employment or other experiences that may qualify you for work with our company. Please
note any licenses, abilities, skills, schooling, or past work experience with regard to the following: Forklift/towmotor operations; measuring devices;
mechanical aptitude; ability to use a tape measure (fractions) and/or micrometers.

EMPLOYMENT HISTORY

Company Name Telephone ###-###-####
Address Employed - (State Month and Year)
From To
Name of Supervisor
Rate/Salary
Starting
Job Title $ Per
Reason for Leaving
Rate/Salary
Final
May We Contact for Reference? Yes No Later $ Per
Describe Your Work

 

Company Name Telephone ###-###-####
Address Employed - (State Month and Year)
From To
Name of Supervisor
Rate/Salary
Starting
Job Title $ Per
Reason for Leaving
Rate/Salary
Final
May We Contact for Reference? Yes No Later $ Per
Describe Your Work

 

Company Name Telephone ###-###-####
Address Employed - (State Month and Year)
From To
Name of Supervisor
Rate/Salary
Starting
Job Title $ Per
Reason for Leaving
Rate/Salary
Final
May We Contact for Reference? Yes No Later $ Per
Describe Your Work

 

Company Name Telephone ###-###-####
Address Employed - (State Month and Year)
From To
Name of Supervisor
Rate/Salary
Starting
Job Title $ Per
Reason for Leaving
Rate/Salary
Final
May We Contact for Reference? Yes No Later $ Per
Describe Your Work

REFERENCES

Please include professional associates who could be contacted for an employment reference.

Name
Relationship
Occupation
Phone Number
###-###-####
###-###-####
###-###-####

PLEASE READ THE STATEMENT BELOW CAREFULLY: APPLICANT AUTHORIZATION TO RELEASE RECORDS

Please choose MAY or MAY NOT below.

By pressing the SUBMIT button, I understand that any employment with Jackson Tube Service is voluntarily entered into and, if employed, I may resign at any time for any reason. Similarly, Jackson Tube Service may terminate the employment relationship when it is in its best interest to do so.

I authorize the investigation of all statements contained in this application, and further authorize Jackson Tube Service to contact my past employers. My present employer MAY MAY NOT be contacted. I certify that all statements and information are true, and acknowledge that any falsification of these facts will disqualify me for employment consideration and/or may be cause for separation from Jackson Tube Service's employment.

I hereby consent and authorize Jackson Tube Service, and any of its agents, to secure information pertaining to my background. I understand that the information supplied by me can be utilized in conducting a background investigation which may include, but not be limited to, criminal history search, driving record history, and verification of any information provided on the application form. I release from liability all persons, companies, and corporations supplying information as a result of this investigation. I further release and indemnify Jackson Tube Service and any of its agents against any liability that might result from conducting such investigations.

In the event I am extended an offer of employment, I understand that I will undergo a physical examination that will be conducted by a company-designated physician.