Application for Employment

To Applicant: We deeply appreciate your interest in our organization and assure you that we are sincerely interested in your qualifications. A clear understanding of your background and work history will aid us in placing you in the position that best meets your qualifications and may assist us in possible future upgrading.

SPEEDGRIP CHUCK COMPANY

An Equal Opportunity Employer

APPLICATION FOR POSITION

Speedgrip Chuck Company does not discriminate in hiring or employment on the basis of race, color, religion, creed, national origin, sex, ancestry, or on the basis of handicap unrelated to your ability to perform the work for which you applied. No question on this application is intended to secure information to be used for such discrimination.

The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age and Speedgrip Chuck Company fully adheres to the spirit and rules of this Act.

This application will be given every consideration, but its receipt does not imply that the applicant will be employed.

Thank You for Applying

Our team will review and follow up if your qualifications match our needs.

Full Name*

Address (Number and Street)*

City*

State*

Zip Code*

Phone*

Email*

Position applied for

Machinist Clerical Other

If Other, please specify

Date available for work

Employment type

Full time Part time

If part time: Hours

If part time: Days

Willing to work nights?

Yes No

17 years of age or older (18 years if applying for machinist position)

Yes No

Health Record

The following information will be used only to the extent that it is relevant to the qualifications and position for which you apply and is requested in concern for your safety and that of fellow employees.

How much time have you lost from work or school during each of the past three years due to accidents or illness (include time lost for colds, etc. and sick days at home if during periods of unemployment).

No. of Days (most recent year)

Nature of Illness (recent year)

No. of Days (prior year)

Nature of Illness (prior year)

No. of Days (two years ago)

Nature of Illness (two years ago)

Do you have any impairments (physical, mental or medical) which would interfere with your ability to do the job for which you have applied? If so, please explain:

Speedgrip Chuck Company will make all reasonable and practical arrangements to accommodate for any employee's handicaps and physical or mental limitations.

Education

Information contained in this section will be used only to the extent that it is relevant to the qualifications and position for which you apply. At least the city and state must be included in the address.

Elementary - School Name and Address

Elementary - Did You Graduate?

Yes No

High School - School Name and Address

High School - Did You Graduate?

Yes No

College - School Name and Address

College - Did You Graduate?

Yes No

Business or Trade School - School Name and Address

Business or Trade School - Did You Graduate?

Yes No

Graduate School - School Name and Address

Graduate School - Did You Graduate?

Yes No

Correspondence or Night School - School Name and Address

Correspondence or Night School - Did You Graduate?

Yes No

Employment Record

Starting with PRESENT or MOST RECENT, list all previous employers. List only employers located within the United States. Include self-employment, summer and part time jobs.

Employer 1 - Name and Address

Employer 1 - Dates Employed

Employer 2 - Name and Address

Employer 2 - Dates Employed

Employer 3 - Name and Address

Employer 3 - Dates Employed

Employer 4 - Name and Address

Employer 4 - Dates Employed

Employer 5 - Name and Address

Employer 5 - Dates Employed

A. Office Training and Experience

If applying for a nonexempt office position, indicate what office machines and equipment you have operated or skills you have acquired through training or experience.

Office equipment and skills

Typewriter Calculator Computer Other

If Other, please explain

Number of years of training

Number of years of experience

B. Manufacturing Training and Experience

If applying for an hourly, non-exempt position, please summarize manufacturing training and experience below.

Name of firm

Address

When

Duties (include training and experience on machine operations)

Other Relevant Information

Please use the space provided below to indicate any special activities, experiences, or other background information which should assist the company in evaluating your application and qualifications for the position you are applying for:

Military Service

Have you served in the United States Armed Forces?

Yes No

If Yes, which Service?

What branch of that Service?

Starting Rank

Service start date

Service end date

Nature of Duties and Training

Are you currently in a reserve capacity with the National Guard, or other reserve organization where summer training is mandatory?

Yes No

Personal References

Give two personal references (other than employers, family, or relatives) who are mature persons and who have known you for the past (5) years or more.

Reference 1

Name

Occupation

Address

Years Acquainted

Reference 2

Name

Occupation

Address

Years Acquainted

Notice to Applicants

Please be aware that all applicants for employment may be required to submit to urinalysis, blood tests or other screening, as part of a pre-employment physical examination, for the purpose of detecting the presence of alcohol or illegal drugs. Applicants tested will be required to sign a Consent/Release form prior to testing, and any applicant refusing to sign any required form will be disqualified from further consideration.

Please read before signing

If you have any questions regarding this statement or questions contained on this application, please ask them of an employment interviewer before signing.

I affirm that information contained in this application is true and complete and that any misrepresentation, falsification, or omission, heron, shall be sufficient reason for dismissal from, or refusal of, employment. Further, I authorize and release Speedgrip Chuck Company to investigate and verify any one or more of my statements and answers contained on this application.

Additionally, I hereby authorize and release all my former employers, educational institutions, and other references reflected on this application to answer any inquires or questions of Speedgrip Chuck Company. As a precondition to employment, I agree to submit upon request to a physical examination to be performed at company expense by a physician designated by the company. If selected for employment and as a condition of continued employment, I further agree to submit upon request and at company expense to physical examinations to be performed by a physician designated by the company.

If employed by Speedgrip Chuck Company and as consideration for such employment, I agree that during and after such employment, I will not divulge or appropriate to my own use or the use of others, except as you authorize or direct, any secret or confidential information or knowledge obtained by me during such employment.

I understand that if hired, I have the right to terminate my employment at any time, with or without cause and with or without notice. I further understand that Speedgrip Chuck Company has the same right. In addition, I understand and agree that no one except the President of Speedgrip Chuck Company has the authority to enter into any agreement contrary to the previous statements, and then only if it is in writing and signed by the President.

I hereby acknowledge that I have read the above statements and understand the same.

Accept*

I accept the terms above

Signature of Applicant*

Date*

You may also email your resume to sbaral@speedgrip.com after submitting this application.