Application For Employment

Name *

First

Last

Street Address *

City *

State *

Zip Code *

Phone # *

Are you at least 18 years of age or obtain a state work permit? *

Yes
No

Are you either a U.S. Citizen or non-citizen with authorization to work in the United States? *

Yes
No

(If “YES” – you must complete the I-9 Form required by the U.S. Immigration and Naturalization Service no later than three (3) business days after your date of hire.)

Position Applied For: *

Full-Time
Part-Time
Seasonal

Date of Availability *

Have you ever applied for employment with this company? *

Yes
No

If so, in what position?

Do you have special skills or operator experience?

Yes
No

Name of Employer #1: *

Start with your present or most recent position and list all relevant work experience.

Phone #:

Full Address (# Street, City, State, Zip)

Supervisor Name/Title:

Job Title:

Employed From: Month/Yr

To: Month/Yr

Reason For Leaving

Rate of Pay

May we contact this employer?

Yes
No

Name of Employer #2: *

Start with your present or most recent position and list all relevant work experience.

Phone #:

Full Address (# Street, City, State, Zip)

Supervisor Name/Title:

Job Title:

Employed From: Month/Yr

To: Month/Yr

Reason For Leaving

Rate of Pay

May we contact this employer?

Yes
No

Name of Employer #3: *

Start with your present or most recent position and list all relevant work experience.

Phone #:

Full Address (# Street, City, State, Zip)

Supervisor Name/Title:

Job Title:

Employed From: Month/Yr

To: Month/Yr

Reason For Leaving

Rate of Pay

May we contact this employer?

Yes
No

Highest Grade Completed:

Years of College:

Name of Last School Attended:

Attended under different name? (please provide)

Degree Obtained:

Address (# Street, City, State, Zip):

Course of Study:

Reference #1: *

Provide 3 individuals whom you are not related to that you have known for at least 1 year.

Occupation: *

Contact Phone #: *

Title/Relationship: *

Reference #2: *

Provide 3 individuals whom you are not related to that you have known for at least 1 year.

Occupation: *

Contact Phone #: *

Title/Relationship: *

Reference #3: *

Provide 3 individuals whom you are not related to that you have known for at least 1 year.

Occupation: *

Contact Phone #: *

Title/Relationship: *

Where did you hear about Phoenix Glass?

I understand that any misstatement, omission or misleading information given in my application, resume or interview or in connection with other company records may result in the rejection of my application, the withdrawal of any offer of employment or my dismissal. Subject to the provisions of the Fair Credit Reporting Act, I authorize an investigation of all statements contained in this application for employment. I release from all liability and responsibility all persons and entities requesting or supplying information about any information provided on this application, including my present employer. I acknowledge that any offer of employment is contingent upon my satisfactorily completing a background check and a pre-employment medical examination and inquiry. Such medical exam or inquiry may include a pre-employment drug test. My offer of employment may be revoked if it is determined that I cannot perform the essential job functions of the position with or without a reasonable accommodation, or if providing a reasonable accommodation would impose an undue hardship on the company or if my employment would pose a direct threat of substantial harm to myself or others. I understand that if employed, I will be an employee at-will, which means either I or the Company can end my employment at any time without cause or notice. No statement, whether written or oral, by any company representative other than a written statement by the Company President may vary the foregoing. *

Yes
No

Signature (Type Name) *

Date *