Employment Application

Location you would like the application sent to:

Avilla, Indiana

Champaign, Illinois

Applicant Information

Name *

First

Name

M.I.

Name *

Last

Date

Address *

Address

Street Address Cont.

City

State/Province

Zip/Postal

Phone *

Email *

Date Available *

Desired Salary *

Position Applied for *

Date of Birth *

Are you a citizen of the United States? *

Yes

No

Are you authorized to work in the U.S.? *

Yes

No

Have you ever worked for this company? *

Yes

No

When *

Have you ever been convicted of a felony? *

Yes

No

Please explain why *

How did you hear about Wirco Inc.? *

Education

High School *

Address *

Address

City

State/Province

Zip/Postal

From *

To

Did you graduate? *

Yes

No

Degree

College

Address

City

State/Province

Zip/Postal

From

To

Did you graduate?

Yes

No

Degree

Other

Address

City

State/Province

Zip/Postal

From

To

Did you graduate?

Yes

No

Degree

Please list three professional references:

Full Name *

Relationship *

Company *

Phone *

Address *

Address

City

State/Province

Zip/Postal

Full Name *

Relationship *

Company *

Phone *

Address *

Address

City

State/Province

Zip/Postal

Full Name *

Relationship *

Company *

Phone *

Address *

Address

City

State/Province

Zip/Postal

Previous Employment

Company

Phone

Address

City

State/Province

Zip/Postal

Supervisor

Job Title

Skills Used

Responsibilities

From

To

May we contact your previous supervisor for a reference?

Yes

No

Company

Phone

Address

City

State/Province

Zip/Postal

Supervisor

Job Title

Skills Used

Responsibilities

From

To

May we contact your previous supervisor for a reference?

Yes

No

Company

Phone

Address

City

State/Province

Zip/Postal

Supervisor

Job Title

Skills Used

Responsibilities

From

To

May we contact your previous supervisor for a reference?

Yes

No

Military Service

Branch

From

To

Rank at Discharge

Type of Discharge

If other than honorable, explain

General

Subjects or Special Study or Research Work

Job Related Skills (computer, driver's license certifications, etc.

Hobbies

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Date *

Signature *

If you are to be hired by the company, you will be required to attest to your identity and employment eligibility, and to present documents confirming your identity and employment eligibility. You cannot be hired if you cannot comply with these requirements.

AUTHORIZATION

I certify that the facts contained in this application (and accompanying resume, if any) are true and complete to the best of my knowledge. I understand that any false statement, omission, or misrepresentation on this application is sufficient cause for refusal to hire, or dismissal if I have been employed, no matter when discovered by the Company.

I understand that any employment is conditioned on a background check. I authorize the Company to thoroughly investigate all statements contained in my application or resume, and I authorize my former employers and references to disclose information regarding my former employment, character and general reputation to the company, without giving me prior notice of such disclosure. In addition, I release the Company, any former employers and all references listed above from any and all claims, demands or liabilities arising out of or related to such investigation or disclosure.

I understand and agree that nothing contained in this application, or conveyed during any interview, is intended to create an employment contract. I further understand and agree that if I am hired, my employment will be ‘at will’ and without fixed term, and my be terminated at any time, with or without cause and without prior notice, at the option of either myself or the Company. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon the Company unless made in writing by an authorized Company representative.

If I am offered employment I agree to submit to a medical examination and drug test, if required, before starting work. If employed, I also agree to submit to a medical examination or drug test at any time deemed appropriate by the Company and as permitted by law. I consent to such examinations and tests, and I request that the examining doctor disclose to the Company the results of the examination, which results shall remain confidential and segregated from my personal file. I understand that my employment or continued employment, to the extent permitted by law, is contingent upon satisfactory medical examinations and drug test, if required, and if I am hired a condition of my employment will be that I abide by the Company’s Drug and Alcohol Policy.

I understand that acceptance of this form does not indicate there is a position open and does not obligate the Company to hire. If hired, I agree to abide by all Company work rules, policies and procedures. The Company retains the right to revise its policies or procedures, in whole or in part, at any time.

Date *

Signature *

If you are to be hired by the company, you will be required to attest to your identity and employment eligibility, and to present documents confirming your identity and employment eligibility. You cannot be hired if you cannot comply with these requirements.