APPLICATION FOR EMPLOYMENT

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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.

Full Nameyour full name
AddressNumber and Street
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City
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Zip Code
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Telephone
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Position applied for:
If Other, please specify
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Date available for work:
If part time:
Willing to work nights?
17 Years of age or older:18 years if applying for machinist position
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).

Nature of Illness
Nature of Illness
Nature of Illness

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:

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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.

ElementarySchool Name and Address
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Did You Graduate?
High SchoolSchool Name and Address
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Did You Graduate?
CollegeSchool Name and Address
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Did You Graduate?
Business or Trade SchoolSchool Name and Address
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Did You Graduate?
Graduate SchoolSchool Name and Address
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Did You Graduate?
Correspondence or Night SchoolSchool Name and Address
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Did You Graduate?
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 Name and Addressmore details
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Dates Employed
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Employer Name and Addressmore details
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Dates Employed
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Employer Name and Addressmore details
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Dates Employed
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Employer Name and Addressmore details
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Dates Employed
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Employer Name and Addressmore details
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Dates Employed
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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.

If Other, please explain:more details
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Number of years of trainingmore details
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Number of years of experiencemore details
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B. Manufacturing Training and Experience

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

Name of firmmore details
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Addressmore details
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Whenmore details
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Duties (include training and experience on machine operations)more details
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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:
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MILITARY SERVICE
Have you served in the United States Armed Forces?
If Yes, which Service?
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What branch of that Service?more details
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Starting Rankmore details
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Nature of Duties and Trainingmore details
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Are you currently in a reserve capacity with the National Guard, or other reserve organization where summer training is mandatory?
PERSONAL REFERENCES
Add some text or HTML here

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.

Namemore details
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Addressmore details
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Occupationmore details
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Years Acquaintedmore details
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Namemore details
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Addressmore details
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Occupationmore details
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Years Acquaintedmore details
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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.
Signature of Applicationyour full name
Dateof appointment
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