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Employment Form (English)
Personal Information
Social Security Number*

E-Mail:*

First Name:*

Middle Initial

Last Name:*

Address Line 1:*

Address Line 2:

City:*

State:*

Zip Code:*

Home Phone:*

Business Phone:

Cell Phone:

May we contact you at your work number?
Yes No 

Are you at least 18 years of age
Yes No 

Do you have the legal right to work in the United States*
Yes No 

If applying for a job requiring driving, do you have a valid California Drivers` License?*
Yes No 

Have you ever been convicted of a crime OTHER THAN (1) a marijuana-related conviction circumstances of that occurred more than two year ago; and (2) an offense for which you were referred to, participated in, any pre-trial or post-trial diversion program?

Yes
No

Are you currently under arrest or released on bond or on your own recognizance, pending trial for a criminal offense?*
Yes No 

Note: This Company will not deny employment to any applicant solely because the person has been convicted of a criminal offense. This Company, however, may consider the nature, date and the offense, as well as whether the offense is relevant to the duties of the position applied for.
Availability
Date Available*

Postion Applied For:*

Minimum Acceptable Annual Salary:*

Employment Requested:*
Full Time Part Time Temporary Day Night 

Education
High School:

Location

Diploma Received:*
Diploma
Equivalency
None

Junior College

Location

Did you graduate
Yes No 

Degree Earned:

Attended from:

Attended To:

Major/Minor:

College / University

Location

Did you graduate
Yes No 

Degree Earned:

Attended from:

Attended To:

Major/Minor:

Graduate School

Location

Did you graduate
Yes No 

Degree Earned:

Attended from:

Attended To:

Major/Minor:

Trade School

Location

Did you graduate
Yes No 

Degree Earned:

Attended from:

Attended To:

Major/Minor:

Employment History
Name Of Employer:*

Address Line 1:*

Salary

City:*

State:*

Zip Code:*

Employed From:*

Employed To:*

Employer Phone:*

Job Title:*

Supervisor Name:*

Reason For Leaving:*

Name Of Employer:

Address Line 1:

Salary

City:

State:

Zip Code:

Employed From:

Employed To:

Employer Phone:

Job Title:

Supervisor Name:

Reason For Leaving:

Name Of Employer:

Address Line 1:

Salary

City:

State:

Zip Code:

Employed From:

Employed To:

Employer Phone:

Job Title:

Supervisor Name:

Reason For Leaving:

Name Of Employer:

Address Line 1:

Salary

City:

State:

Zip Code:

Employed From:

Employed To:

Employer Phone:

Job Title:

Supervisor Name:

Reason For Leaving:

Please identify and explain all periods of unemployment, other than approved Leaves of Absence in th

May we contact the employers listed above?*
Yes
No

If not, please indicate which one(s) you do not wish us to contact

Skills Section
Foreign Languages: (Proficiency to speak, read or write)*

Machines Operated

Typing?
Yes No 

Computer Skills

Other Skills / Certificates

Professional References


Please list four references that have knowledge of your professional experience.


Reference Name:*

Relationship

Address:*

Occupation:*

Employer

Phone:*

Reference Name:*

Relationship

Address:*

Occupation:*

Employer

Phone:*

Reference Name:*

Relationship

Address:*

Occupation:*

Employer

Phone:*

Reference Name:*

Relationship

Address:*

Occupation:*

Employer

Phone:*

Do you have any relatives employed by this Company or any of its subsidiaries?
Yes No 

If "Yes", give details

Name of Relative

Relationship

Facility

Position

Name of Relative

Relationship

Facility

Position

Referral
How were you referred to this Company
Internet / Job Board

Newspaper

Employee

Agency

School

Other

Give names of each checked

Have you ever worked for this Company or any of its subsidiaries? If "Yes", give details below*
Yes No 

Facility

Employed From:

Employed To:

Position

PLEASE READ CAREFULLY AND SIGN BELOW:

I certify that the information contained in this application is correct to the best of my knowledge. I understand that falsification of this information or material omission may result in the refusal to hire or the termination of my employment at any time.

I give the Company the right to make a thorough investigation of my past employment, education, financial background, and activities. I release all persons or entities from all liability for any damage that may result from furnishing information to the Company. I also release the Company and all of its employees from all liability for any damage that may result from the Company’s reliance on the information furnished.

My employment with the Company shall be contingent upon my successful completion of a post-offer medical examination and/or other medical tests for alcohol, drugs and controlled substances which may include a blood or urine sample. Prior to testing, I agree to sign the Company’s authorization forms wherein I will agree to submit to such testing and to authorize the release of the results to the Company. The physical examination and substance test will be conducted at the Company’s expense by a health care provider selected by the Company. I understand that I am not entitled to wages for time spent in Safety Training and Orientation, which may be for 3-6 hours.

I must produce applicable documents showing that I am a United States citizen or alien lawfully authorized to work in the United States, within the time frame specified by the Company, to meet the Immigration Reform and Control Act of 1986 requirements.

In consideration of my employment, I agree to conform to the Company’s policies, rules and regulations. I understand and agree that my employment is at-will, and therefore, my employment and compensation can terminate, with or without cause, and with or without notice, at any time, at my option or the Company’s option. I further understand and agree that this at-will employment relationship as defined above will remain in effect throughout my employment with the Company, or any of its parent or affiliated companies, unless it is modified by a specific, express written employment contract which is signed by the President of the Company and me. This represents an integrated policy with respect to the at-will nature of the employment relationship.
Signature

Date


Authorization for Release of Medical Records

I acknowledge that my employer, General Coatings Corporation (“The Company”), is concerned about my ability to perform my job. I further acknowledge that I have been requested by the Company to submit to a pre-placement physical to be administered by the Company’s designated medical clinic and/or laboratory, whose purpose and function is to determine whether I am able to perform my described job duties.

I hereby authorize the medical clinic and/or laboratory to disclose whether I am able to perform the essential function of the job duties and whether I have passed or failed the pre-placement physical test.

I acknowledge that executing this authorization is voluntary and I have the right to receive a copy of this authorization if I request one.


Name

Date

“To insure good health: eat lightly, breathe deeply, live moderately, cultivate cheerfulness, and maintain an interest in life.”
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