Stebbins Engineering and Manufacturing Company

Date

Name:

Last: *

First: *

Middle:

Social Security No.(optional):

Address:

Apt.

Number and Street: *

City: *

State: *

Zip Code: *

Telephone: *

How were you referred for employment :

How were you referred for employment:

Have you ever worked for Stebbins before?

Yes

If so, when?

Have you applied for work with Stebbins before?

Yes

If so, when?

Position applying for:

Wage or salary requested: $

Date available for work:

Are there any aspects of the job for which you are applying you are unable to accomplish?

Yes

If yes, please specify:

Type of employment desired:

Full Time

Part Time

Will you work:

Overtime

Evenings

Weekends?

If part time, please state the number of hours and what days you wish to work:

Is there any time of the day or any day of the week you are unable to work?

Yes

If yes, please specify:

Are you presently employed?

Yes

Why do you wish to change jobs?

Do you have the legal right to work in the United States? (If hired, proof of status will be required)

Yes

Are you over 18 years of age? (If hired, proof of status will be required)

Yes

Do you intend to work anywhere else in addition to working at Stebbins?

Yes

If so, where?

Do you have a drivers license?

Yes

State:

Commercial/Operator's Number:

Expiration Date:

Have you ever been bonded?

Yes

If yes, for what job(s)?

Have you ever been denied bond coverage?

Yes

If yes, explain:

EMPLOYMENT HISTORY: Please list all positions for the past 10 years, giving present or last positions first. Use additional pages if necessary.

Dates Worked:

From:

To:

Employer's Name:

Supervisor's Name:

Reason for Leaving:

Supervisor's Title:

Supervisor's Telephone No.:

Employer's Address

Street:

City:

State:

Zip:

Job Title and Duties:

Dates Worked:

From:

To:

Employer's Name:

Supervisor's Name:

Reason for Leaving:

Supervisor's Title:

Supervisor's Telephone No.:

Employer's Address

Street:

City:

State:

Zip:

Wage or Salary:

Dates Worked:

From:

To:

Employer's Name:

Supervisor's Name:

Dates Worked:

From:

Starting:

City:

State:

Zip:

Job Title and Duties:

Dates Worked:

From:

To:

Employer's Name:

Supervisor's Name:

Reason for Leaving:

Supervisor's Title:

Supervisor's Telephone No.:

Employer's Address

Street:

City:

State:

Zip:

Job Title and Duties:

Dates Worked:

From:

To:

Employer's Name:

Supervisor's Name:

Reason for Leaving:

Supervisor's Title:

Supervisor's Telephone No.:

Employer's Address

Street:

City:

State:

Zip:

Job Title and Duties:

May we contact the employers listed above?

Yes

If not, indicate by number which one(s) we may not contact and state why:

Please account for all periods of unemployment longer than three (3) months:

Were you in the U.S. Armed Forces?

Yes

If so, what branch?

Dates of duty:

From:

To:

List duties in the service including special training:

What office or warehouse machines/tools can you operate:

SKILLS & TRAINING ACQUIRED

Typing (WPM):

CRT/Data Entry (WPM):

Word Processing: Programs

Switchboard: Type:

Shorthand Dictation (WPM)

Computer (list types and programs)

Calculator by touch

Fax

Photocopier

Filing

Bookkeeping

Accounting

EDUCATION:

NAME AND ADDRESS OF SCHOOL:

COURSE OF STUDY:

SELECT LAST  YEAR COMPLETED:

GRADUATED?

DEGREE OR DATE LAST ATTENDED:

High School:

Yes

College:

Yes

Other:

Yes

List any additional work experience, skills, information, licenses, certifications, special study, or research work relating to position applied for or of general interest:

Is any information necessary to enable a check of your records such as a change of name, use of an assumed name, or nickname? If yes, please explain

PLEASE LIST ANY RELATIVES OR FRIENDS EMPLOYED CURRENTLY OR IN THE PAST BY STEBBINS:

Name:

Relationship:

Where Employed:

Name:

Relationship:

Where Employed:

Name:

Relationship:

Where Employed:

PERSONAL REFERENCES: Please list three business professionals, or other persons who are not relatives, former employers, or employees of The Stebbins Engineering and Manufacturing Company who can act as a reference for you.

Name:

How long known:

Occupation:

Telephone:

Complete Address:

Name:

How long known:

Occupation:

Telephone:

Complete Address:

Name:

How long known:

Occupation:

Telephone:

Complete Address:

Email:

IMPORTANT: READ CAREFULLY & SIGN BELOW

In signing below, I certify that my answers to the foregoing questions on the employment application submitted to The Stebbins Engineering and Manufacturing Company (“Stebbins” or ”the Company”) are true and correct and understand that any false or misleading information on the application shall be sufficient cause for rejection of my employment application or, if hired, termination of my employment. I understand that if considered for employment, I may be subject to background screenings and/or investigations including without limitation review of consumer credit reports pertaining to me. I hereby authorize the release of information stemming from such screenings or investigations including the release of information from my former employers educational institution(s) I attended and from other individuals and/or entities that may have responsive information provided that the release of such information is not otherwise prohibited by law

In making this application for employment, it is understood and accepted that as part of the application and employment process, and/or during employment with the Company, I may be asked to submit to physical examinations which may include testing for alcohol and drugs, and/or be fingerprinted, all in accordance with applicable law. By signing this application, I hereby agree to submit to such examinations, tests, and fingerprinting.

I understand that the use of this form does not indicate that there are positions open at Stebbins and does not in any way obligate Stebbins to extend an offer of employment to me. If chosen for employment, I agree to abide by and observe all Company rules and regulations. I further understand that any such future employment is terminable by either party at will with or without notice or cause in accordance with applicable law. No person other than the Director of Human Resources of Stebbins is authorized on behalf of Stebbins to modify or amend the provisions stated herein.

DATE

SIGNATURE

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