| To: |
Sheila
M. Meyers
Human Resources |
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| Personal
Information |
Name (Last)
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(First)
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(Middle)
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Home Phone
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Other Phone
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Social Security Number
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Address
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City
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State
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Zip
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Position Applied for:
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State age if under 18:
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| Do you have the legal right to
work or be employed in the United States? If yes, as a condition of employment, you are
required to submit proof of employment eligibility and identity in compliance with the
Immigration Reform and Control Act of 1986. |
Yes |
No |
| Have you been convicted of any crime other
than a minor traffic offense within the last five years? |
Yes |
No |
| If yes, give nature of crime, when, where,
and disposition of case (conviction of a crime is not an automatic bar to employment). |
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| Record of
Education |
| School |
Name and Address of
School |
Course of Study |
Last Year Completed |
Did You Graduate? |
List Degree or Diploma |
| Pre-High |
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| High |
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| College |
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| Trade
Technical Other
(Specify) |
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| Record of
Employment |
| List
below all present and past employment, beginning with your
most recent. |
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Name and Address of
Company and Type of Business |
From: |
To: |
Job
Title |
| 1 |
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Describe
the work you did: |
Starting Pay |
Ending Pay |
Name of Supervisor |
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Telephone:
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Reason
for leaving: |
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Name and Address of
Company and Type of Business |
From: |
To: |
Job
Title |
| 2 |
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Describe
the work you did: |
Starting
Pay |
Ending
Pay |
Name of Supervisor |
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Telephone:
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Reason
for leaving: |
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Name and Address of
Company and Type of Business |
From: |
To: |
Job
Title |
| 3 |
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Describe
the work you did: |
Starting Pay |
Ending Pay |
Name of Supervisor |
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Telephone:
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Reason
for leaving: |
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Name and Address of
Company and Type of Business |
From: |
To: |
Job
Title |
| 4 |
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Describe
the work you did: |
Starting Pay |
Ending Pay |
Name of Supervisor |
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Telephone:
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Reason
for leaving: |
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Click any button if you do not
wish us to contact that employer |
1 |
2 |
3 |
4 |
| Reason |
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| Provide detailed explanation for any gaps in employment above: |
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| Personal
References (Not Former Employers or Relatives) |
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Name and Occupation |
Address |
Phone Number |
| 1 |
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| 2 |
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| 3 |
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Military
Service Record |
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Were you in the U.S. Armed Forces?
Yes No |
if yes, what branch? |
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Dates of duty: From:
To: |
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| Rank at discharge: |
| List duties in the service including special training: |
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| Are you a member of the National Guard? |
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Are you a member of the Reserve? |
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General |
| Would you work Full-Time? Yes No |
Part-Time? Yes No |
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Salary desired: |
Date Available for work: |
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| How were you referred to The Merrick Printing Co., Inc.? |
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| Can you perform the essential function of the job for which you
have applied with or without reasonable accommodation? Yes No |
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| Do you have any friends or relatives in our employment?
Yes
No |
| Names of friends, relatives and
relationship: |
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| Have you ever worked for The Merrick Printing
Co., Inc. before? Yes No |
| If so, please give details: |
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| Dates: |
Position |
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| Are there any other experiences, skills, or qualifications which
you feel would especially fit you for work with The Merrick Printing Co., Inc.? |
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| Certification |
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Please read and indicate your
agreement with the following:
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Equal Employment Opportunity. The Merrick Printing Co., Inc. is
an equal opportunity employer. We do not discriminate against applicants or employees on
the basis of race, color, religion, sex, national origin, age, or physical or mental
disability or veteran status. This policy of nondiscrimination extends to all terms,
conditions and privileges of employment and to all personnel actions.
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Authorization by Applicant. I authorize The Merrick Printing
Co., Inc. to contact my former employers and references listed on this application, and I
authorize such individuals and organizations to release information required by The
Merrick Printing Co., Inc. The information supplied on this application and by way of any
oral statements is true and accurate, and I understand that any misstatement by me may
result in immediate dismissal. I release all parties from all liability for any
damage that may result from furnishing same to you.
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Employment at Will. I agree to the rules and regulations of The
Merrick Printing Co., Inc. upon my acceptance of employment, I understand that my
acceptance of employment does not constitute an employment contract and that my employment
and compensation can be terminated, with or without cause, and with or without notice, at
any time, at the option of either the company or myself and that I will be entitled only
to wages or salary earned through the date of such termination. I understand that no
manager, supervisor or other representative of management, other than the president or
vice president has the authority to enter into an employment contract and that any such
employment contract must be in writing and signed by the employee and by the president or
vice president of the company.
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Effective Period. This application is current only for thirty (30) days, at the
conclusion of which time, if you have not heard from us and still wish to be considered
for employment, it will be necessary for you to fill out a new
application.
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