Employment Application

Today's Date *

Name *

First

Last

Social Security Number :

Telephone Number : *

Birth Date: *

Driver License #: *

Driver Licence Class:

Driver Licence Expiration date: *

Permanent Address- Street & Number : *

City: *

State: *

Zip: *

Country: *

Are you 18 years or older? *

Yes
No

Are you a U.S. Citizen? *

Yes
No

If Non-Citizen, indicate type of Visa:

Resident
Visitor
Student
Other

Have You Ever Been Employed by Vernor Material?

Yes
No

List Below Any Relatives Employed by Us:

Have You Used Any Recreational Drugs in The Past 60 Days? *

Yes
No

Have You Worked for DOW Within the Last 90 Days?

Yes
No

If YES, Please Select Reason for Leaving:

Resigned
Terminated
Reduction of Force
None

Email *

Are You Currently Employed? *

Yes
No

If NO, How Long Since Last Employment? (Years and Months)

Position Applying for:

Years of Experience: (Years and Months)

Second Choice:

Years of Experience: (Years and Months)

REFERENCE #1 Name: (NON-RELATIVE References) *

REFERENCE #1 Phone Number: *

REFERENCE #1 Time Known:

REFERENCE #2 Name: (NON-RELATIVE References)

REFERENCE #2 Phone Number:

REFERENCE #2 Time Known:

REFERENCE #3 Name: (NON-RELATIVE References)

REFERENCE #3 Phone Number:

REFERENCE #3 Time Known:

Employment History 1 : Company Name

Employment History 1 : Company Telephone Number

Employment History 1 : Company Address

Employment History 1 : Type of Business

Employment History 1 : Starting Salary $

Employment History 1 : Ending Salary $

Employment History 1 : From Date

Employment History 1 : To Date

Employment History 1 : Reason for Leaving:

Employment History 1 : May We Contact Previous/Current Supervisor for a Reference?

Yes
No

Employment History 1 : Job Duties and Responsibilities:

Employment History 2 : Company Name

Employment History 2 : Company Telephone Number

Employment History 2 : Company Address

Employment History 2 : Type of Business

Employment History 2 : Supervisor’s Name

Employment History 2 : Reason for Leaving

Employment History 2 : Job Title

Employment History 2 : Starting Salary $

Employment History 2 : Ending Salary $

Employment History 2 : From Date

Employment History 2 : To Date

Employment History 2 : Reason for Leaving:

Employment History 2 : May We Contact Previous/Current Supervisor for a Reference?

Yes
No

Employment History 2 : Job Duties and Responsibilities:

DRIVERS SECTION ONLY 1 - State

DRIVERS SECTION ONLY 1 - License Number

DRIVERS SECTION ONLY 1 - Class

DRIVERS SECTION ONLY 1 - Expiration Date

DRIVERS SECTION ONLY 2 - State

DRIVERS SECTION ONLY 2 - License Number

DRIVERS SECTION ONLY 2 - Class

DRIVERS SECTION ONLY 2 - Expiration Date

LIST ALL YOUR TRAFFIC CONVICTIONS & FORFEITURES FOR THE PAST THREE YEARS 1: Location

LIST ALL YOUR TRAFFIC CONVICTIONS & FORFEITURES FOR THE PAST THREE YEARS 1 : Date

LIST ALL YOUR TRAFFIC CONVICTIONS & FORFEITURES FOR THE PAST THREE YEARS 1 : Charge

LIST ALL YOUR TRAFFIC CONVICTIONS & FORFEITURES FOR THE PAST THREE YEARS 1: Penalty

LIST ALL YOUR TRAFFIC CONVICTIONS & FORFEITURES FOR THE PAST THREE YEARS 2 : Location

LIST ALL YOUR TRAFFIC CONVICTIONS & FORFEITURES FOR THE PAST THREE YEARS 2 : Date

LIST ALL YOUR TRAFFIC CONVICTIONS & FORFEITURES FOR THE PAST THREE YEARS 2 : Penalty

LIST ALL YOUR TRAFFIC CONVICTIONS & FORFEITURES FOR THE PAST THREE YEARS 2 : Charge

APPLICATION INFORMATION CERTIFICATION & AUTHORIZATION FOR CONSUMER REPORTS TO BE READ, ACKNOWLEDGED AND SIGNED BY ALL APPLICANTS This certifies that this application was completed by me, and that all entries and information on it are true and correct to the best of my knowledge. I authorize Vernor Material & Equipment Co., Inc., (VME) to make such investigations and inquires of my personal, employment, financial, or medical history and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, or persons, from all liability in responding to inquiries concerning my application. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand also that I am required to abide by all rules and regulations of the company, as permitted by law. I understand VME has a Ninety (90) Day Probationary Period after employment where VME may terminate my employment without giving cause. I also understand that if any protective equipment given to me is lost or damaged, I am responsible to replace it. In connection with your application for employment (including contract for services), understand that consumer reports or investigative consumer reports which may contain public record information may be requested or made on you including consumer credit, criminal records, driving record, education, prior employer verification, worker’s compensation claims and others. These reports will include experience information along with reasons for termination of past employment. Further, understand that information from various Federal, State, Local and other agencies which contain your past activities will be requested. A consumer report containing injury and illness records and medical information may be obtained only after a tentative offer of employment has been made. By signing below, you hereby authorize without reservation, any party or agency contacted by this employer to furnish the above mentioned. You further authorize ongoing procurement of the reports at any time during your employment or contract. You also agree that a fax or photocopy of this authorization with your signature be accepted with the same authority as the original. You have the right to make a request of First Advantage, upon proper identification and the payment of any legally permissible fees, for the information in its files on you at the time of your request. You hereby authorize and request, without any reservation, any present or former employer, school, police department, financial institution, division of motor vehicles, consumer reporting agencies, or other persons or agencies having knowledge about you to furnish VME with any and all background information in their possession regarding you, in order that your employment qualifications may be evaluated. Electronic Signature of Applicant (please type your name as you would sign): *

Date: *

Print Name: *

Widget Area 1

Widget Area 2

Widget Area 3