Application for Employment

Position Applied For: *

Referral Source:

Name: * First Last

Email

Are you at least 18 years of age? *

Yes No

What is your citizenship?

US Citizen Legal Permanent Resident Other

May we contact your current employer? *

Yes No

Are you on layoff status or subject to recall elsewhere? *

Yes No

Pay expected: *

If hired, how long do you plan to continue working for the company? *

Do you wish to work: *

Full-time Part-time Temporary

Are you willing and available to work? *

On call Days Evenings Nights Overtime Weekends Holidays

Do you have a valid driver's license? *

Yes No

Many of our jobs involve exposure to heavy lifting, heavy pulling and operating or working with moving machinery and vehicles. Many of our jobs require strong physical strength/endurance, good hearing and eyesight, and the ability to follow safety and other directions. Is applicant able to perform and meet all of those requirements with or without accomodation? *

Yes No

Explain:

Do you have any relatives working for us? *

Yes No

If so, who?

Some positions involve exposure to fumes and/or dust particles in the air. Such positions require the use of dust masks, respirators, and related equipment. Does the applicant have any physical limitations that would prohibit him/her from using required equipment for these positions? *

Yes No

Explain:

Please state whether you have been convicted or plead guilty to any crime or misdemeanor within the last ten years, or if you have been released from prison within the last ten years.* *

Yes No

* A "yes" answer will not necessarily bar applicant from employment.

Describe the nature of the criminal offense and the data of the conviction or guilty plea:

Is there any reason you might be unable to meet our attendance requirements? *

Yes No

If yes, please explain:

Have you previously applied with us? *

Yes No

When:

Have your previously worked with us? *

Yes No

When:

Have you ever used a different name for employment or any other purpose? If so, please state what name and explain the reason for the use of a different name. *

Card #

Education/Training

High School (Name & Location of School):

Did you graduate?

Yes No Other

Subjects Studied:

College (Name & Location of School):

Did you graduate?

Yes No Other

Subjects Studied:

Other Training (particularly that led to a license or certification):

Did you graduate?

Yes No Other

Subjects Studied:

Are you taking or do you plan to take any additional education? If so, what?

Skills/Abilities

List any machines you are skilled in using:

List any skills or abilities you have which are pertinent to the position, including hobbies or related interests:

Job Requirements

Please list work experience, including military and volunteer experience.

Present or Last Employer:

Supervisor: First Last

Rate of Pay $:

Job Title & Duties:

Why did you leave?

Previous Employer:

Supervisor: First Last

Rate of Pay $:

Job Title & Duties:

Why did you leave?

Professional Reference:

Name: First Last

Occupation:

How Long Known:

Attach Resume or Cover Letter (optional)

Cover Letter:

Resume

Please read each of the following items before submitting this application:

1. ACCURACY: I certify that the answers I have provided are true and complete to the best of my knowledge. I understand that if Janicki Industries determines that I have provided false information on this application at any point in the future, Janicki Industries may immediately terminate my employment.

2. EMPLOYMENT-AT-WILL: I understand that Janicki Industries adheres to Washington’s employment-at-will doctrine, meaning that either Janicki Industries or I may end the employment relationship with or without cause, and with or without notice at any time. I acknowledge that no one at Janicki Industries has promised me employment for any specific length of time or specific treatment in specific circumstances.

3. COMPANY PROPERTY: I understand that all company property must be returned to Janicki Industries upon demand, and that I must repay any indebtedness to the company on or before the last day of work. I authorize the company to deduct from my final paycheck, if not deducted earlier, an amount necessary to satisfy any unpaid obligation

4. DRUG TESTING: I understand that if Janicki Industries offers me employment, the company’s offer will be contingent on me submitting to and passing a drug screening test. I consent to such testing.

5. PHYSICAL ASSESSMENTS: I understand that Janicki Industries’ offer of employment may be conditioned on my participation and successful completion of the health assessment pertaining to the use of respiratory and related equipment. I consent to such testing.

6. ANTI-DISCRIMINATION: Janicki Industries fully complies with all applicable discrimination laws including laws that prohibit discrimination on the basis of race, color, religion, sex, sexual orientation, or national origin.

7. INVESTIGATION: I specifically authorize Janicki Industries to investigate all information contained in this application, including but not limited to contacting any named references or previous employers pursuant to the Waiver and Release of Employment Information that I signed. I give any individual that Janicki Industries contacts permission to speak freely about my qualifications and release them from all potential liability.

WAIVER & RELEASE OF EMPLOYMENT INFORMATION

I hereby authorize Janicki Industries to contact references about my work experience and to verify my background, including information given by me. This includes all checks of my background as allowed by law including, but not limited to, discussions with: HR managers, supervisors, co-workers, friends, business associates, education administrators or other individuals that the Company, in its sole discretion, believes may have relevant information regarding my suitability for employment and other checks as the Company deems appropriate.

I agree not to assert any claims or causes of action of any kind against the Company, its agents, its employees, or any individual contacted by the Company, arising out of the Company's investigation and review of information. I further release and forever discharge the Company, its agents, its employees, and the individuals and companies contacted by the Company as part of its investigation, from any and all claims, demands, damages, actions, causes of action, or suits of any kind or nature whatsoever arising from the Company's investigation of my background. I acknowledge that the Company has made no representations of any kind as to whether employment will be offered at the conclusion of its investigation.

I understand that if reference checking reveals false or misleading information given by me, it will be grounds for not hiring me, or if already hired, for immediate dismissal.

Application Agreement: *

I have read and agree to the terms above.

Translated by (if applicable):

Wufoo

Education/Training

Skills/Abilities

Job Requirements

Professional Reference:

Attach Resume or Cover Letter (optional)

Please read each of the following items before submitting this application: