Factory Connection Application – Fill Out and Use This PDF

Application for Employment

Equal access to programs, services, and employment is available to all persons. Those requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department.

PERSONAL INFORMATION

(Please Print Clearly)

If yes, please provide the name and relationship to you:_________________________________________________

BACKGROUND INFORMATION

Have you ever been convicted of, pled guilty to, or admitted guilt to a crime? _____Yes ____No

Answering yes to these questions does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation, and position applied for will be taken into account.

If you answered yes to the above question supply the following information:

Date of Offense:_____________________ Indicate the nature of the conviction:____________________________

________________________________________________________________________________________________.

Have you ever been discharged from a position, or resigned to avoid discharge? ____Yes ____No

If yes describe circumstances:______________________________________________________________________

_________________________________________________________________________________________________.

EDUCATIONAL HISTORY

EMPLOYMENT HISTORY

Provide the following information of your past (4) employers, assignments, or volunteer activities, starting with the most recent.

Current or Most Recent Employer

Employer:______________________________________________ Employer Phone:____________________________

Employer Address:_________________________________________________________________________________

StreetCityState Zip

Exact Position Title:_____________________________________ Average Hours per Week:______________________

Reason for Leaving:_________________________________________________________________________________

Supervisor's Name:______________________________________ Supervisor's Phone:__________________________

Duties:____________________________________________________________________________________________

May Factory Connection contact this employer about your character, qualifications and employment record?

____Yes ____No

Second Most Recent Employer

Employer:______________________________________________ Employer Phone:____________________________

Employer Address:_________________________________________________________________________________

StreetCityState Zip

Exact Position Title:_____________________________________ Average Hours per Week:______________________

Reason for Leaving:_________________________________________________________________________________

Supervisor's Name:______________________________________ Supervisor's Phone:__________________________

Duties:____________________________________________________________________________________________

May Factory Connection contact this employer about your character, qualifications and employment record?

____Yes ____No

Third Most Recent Employer

Employer:______________________________________________ Employer Phone:____________________________

Employer Address:_________________________________________________________________________________

StreetCityState Zip

Exact Position Title:_____________________________________ Average Hours per Week:______________________

Reason for Leaving:_________________________________________________________________________________

Supervisor's Name:______________________________________ Supervisor's Phone:__________________________

Duties:____________________________________________________________________________________________

May Factory Connection contact this employer about your character, qualifications and employment record?

____Yes ____No

Fourth Most Recent Employer

Employer:______________________________________________ Employer Phone:____________________________

Employer Address:_________________________________________________________________________________

StreetCityState Zip

Exact Position Title:_____________________________________ Average Hours per Week:______________________

Reason for Leaving:_________________________________________________________________________________

Supervisor's Name:______________________________________ Supervisor's Phone:__________________________

Duties:____________________________________________________________________________________________

May Factory Connection contact this employer about your character, qualifications and employment record?

____Yes ____No

UNEMPLOYMENT

Please explain all periods of unemployment in the spaces below. Attach additional sheets if necessary.

REFERENCES

Please provide three work references. If you do not have work references, you may include educational references. Do not include family members as references.

______________________________________________________________________________________________

NameRelationship to youPhone

______________________________________________________________________________________________

NameRelationship to youPhone

______________________________________________________________________________________________

NameRelationship to youPhone

REFERRED TO FACTORY CONNECTION BY:

SKILLS AND QUALIFICATIONS

Summarize any training, skills, license, and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying:

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

APPLICANT'S STATEMENT

I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct. I understand that any information provided by me that is found to be false, incomplete, or misrepresented in any respect, will be sufficient cause to (1) cancel further consideration for application, or (2) immediately discharge me from the employer's service, whenever it is discovered. I expressly authorize, without reservation, the employer, its representatives, employees, or agents, to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I herby waive any and all rights and claims I may have regarding the employer, its agents, employees, or representatives, for seeking, gathering, and using such information in the employment process and all other person, corporations, or organizations for furnishing such information about me. I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state, or federal law. I understand that if offered a position with Factory Connection, I may be required to submit to a pre-employment medical examination, drug screening

and background check as a condition of employment. I understand that unsatisfactory results from, refusal to cooperate with, or any attempt to affect the results of these employment tests and checks will result in withdrawal of any employment offer or terminate employment if already employed. I understand that this application remains current

for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to reapply and fill out a new application. If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute any agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer's are authorized to make any assurances to the contrary and that no implied, oral, or written agreement contrary to the foregoing express language are valid unless they are in writing and signed by the employer's president. I also understand that if I am hired, I will be required to provide proof of identify and legal authority to work in the Untied States and that federal immigration

laws require me to complete an I-9 form in this regard.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT

I certify that I have read, fully understand, and accept all terms of the foregoing Applicant Statement:

Signature

Mark the appropriate response to each statement or question. (T=True; F=False)

Please answer the following questions using a scale of 1 to 10 with 1 indicating you strongly disagree and 10 being you strongly agree.

1.If I'm too tired to drop the required nightly deposit it will be allright to do it the next day. Answer: (Answer using scale 1-10)____________________________________________

2.The store opens at 10:00. If I arrive at 10:00 I will not be tardy.

Answer: (Answer using scale 1-10)____________________________________________

3. I am a great employee if I greet 50% of the customers.

Answer: (Answer using scale 1-10)____________________________________________

4. I should be able to leave the store anytime I need to, even if I have to close it.

Answer: (Answer using scale 1-10)____________________________________________