APPLICATION FOR EMPLOYMENT An Equal Employment Opportunity Employer This application will remain active for one year from date of filing. For consideration after that time, reapplication is required All persons shall have the opportunity to be considered for employment without regard to their race, color, religion or creed, sex, age, national origin or ancestry, citizenship status, physical or mental disability, marital status, sexual orientation, arrest record, or any other personal characteristic protected by federal, state, or local law. Duro Dyne will endeavor to make a reasonable accommodation to the known physical or mental limitations of an applicant or qualified employee with a disability unless the accommodation would impose an undue hardship on the operation of our business. Please advise us if you will require individual assistance completing this form, participating in the interview process, or performing the job for which you are applying. General Information Last Name First Name M.I. Date Street Address Home Phone City and State ZIP Code Business Phone Are you legally authorized to work in the U.S.? YesNo Pursuant to the Immigration Reform and Control Act of 1986, all applicants who are offered employment must produce documents establishing their identity and authorization for employment in the United States. These documents must be produced no later than seventy-two (72) hours after employment commences. In addition, all new hires will be required to verify their employment authorization under oath by signing INS Form 1-9. When will you be able to begin work? If you are under 18, do you have a work permit? YesNo Employment Information Position Desired Full TimePart TimeTemporary Salary/Rate Desired Hours Desired Is there anything that would prevent you from working any day or time? YesNo If yes, please specify the reasons It is not necessary for you to identify unavailability for work because of religious observance or practice or any other protected classification. Subsequent to any job offer, we will consider whether a reasonable accommodation can be made. Have you ever been employed by us? YesNo If yes, give date, location, title, name of supervisor and reason for leaving. Have you ever applied for employment with us? YesNo If yes, give date Do you have any relatives working for us? YesNo If yes, please identify them Personal References Please list the names, addresses and telephone numbers of two personal references who have knowledge of your capability to perform the duties of the position you are seeking. Please exclude relatives and former employers. Educational History School Course of Study Degree/Diploma High School College Graduate School Other Schooling (Vocational, Post-graduate) Employment History EMPLOYER (first most recent) Dates Employed Positions Held Duties Reason for Leaving EMPLOYER (Second most recent) Dates Employed Positions Held Duties Reason for Leaving EMPLOYER (third most recent) Dates Employed Positions Held Duties Reason for Leaving EMPLOYER (fourth most recent) Dates Employed Positions Held Duties Reason for Leaving IS THERE ANY REASON WHY WE SHOULD NOT CONTACT ANY CURRENT OR FORMER EMPLOYER FOR A REFERENCE? YesNo IF YES, PLEASE IDENTIFY THE EMPLOYER AND EXPLAIN WHY NOT. PLEASE INDICATE ANY JOB-RELATED SKILLS AND QUALIFICATIONS YOU POSSESS WHICH WOULD HELP YOU PERFORM THE DUTIES OF THE POSITION YOU ARE SEEKING To the extent required by applicable law, the Company maintains a smoke-free workplace. Applicant’s Statement I have read and fully understand the questions asked in this application. I certify that all of the answers I have given are true, accurate and complete. I understand that the omission and/or misrepresentation of any fact from or on this application or during any interview will result in immediate rejection of my application or if I am hired will be cause for immediate dismissal. Unless I noted otherwise, I authorize the Company to contact all my employment references and personal references, as well as the education institutions I have attended. I further authorize the Company to inquire about, investigate and obtain copies of any records which relate to me from my former employers and educational institutions. I hereby release the Company and all affiliated persons and entities, as well as any person or institution that provides the Company with any lawful information about me, from any and all liability whatsoever resulting from any such lawful inquiry, investigation or communication. If hired, I agree to abide by all of the rules and regulations of the Company. I understand and agree that nothing in this application shall constitute an offer, a contract or a guarantee of employment for a specific period of time. If hired, I understand that my employment may be terminated with or without cause and with or without notice at any time, at the will of the Company or me. I further understand that no representative or agent of the Company, other than the President, has the authority to enter into any agreement for employment for any specific period of time, or to make an agreement contrary to the foregoing. I also understand that any agreement modifying my at-will employment status must be in writing and signed by the President. In addition, I understand that the Company and all plan administrators shall have the maximum discretion permitted by law to administer, interpret, modify, discontinue, enhance or otherwise change all policies, procedures, benefits or other terms and conditions of employment. Signature (Type Your Name) Date
