Maintenance Technician

• First Name
• Last Name
• Company Name
• Address
• City
• State
• Zip Code
• Phone
• Email
• Are you 18 years of age or older?
  • Yes
  • No
• Have you ever been convicted of a crime? Please note that a conviction may not necessarily bar you from employment.
  • Yes
  • No
  • If yes, explain
• Are you a U.S. Citizen or otherwise authorized to work in the United States?
  • Yes
  • No
• Are you a veteran?
  • Yes
  • No
• If yes, describe your education and experience
• Reliable transportation to the job site is your responsibility. Do you have reliable transportation?
  • Yes
  • No
• An essential function of this job requires that you are physically able to lift and lower up to 50 pounds of materials. To do this, you must be able to adjust your body position to bend, stoop, stand, walk, turn and pivot. In addition, you must work in an environment with variable temperatures and must be able to read words and numbers. Can you perform these essential functions with or without reasonable accommodations?
  • Yes
  • No

• Position
• Date you can start
• Salary Desired
• Are you employed now?
  • Yes
  • No
• If so, may we contact your present employer?
  • Yes
  • No
• Have you previously applied to Custom Rubber Corp?
  • Yes
  • No

• Grammar School
  • Name
  • City
  • State
  Did you graduate?
  • Yes
  • No
• High School
  • Name
  • City
  • State
  Years Completed
  • 1
  • 2
  • 3
  • 4
  Did you graduate?
  • Yes
  • No
• College
  • Name
  • City
  • State
  Years Completed
  • 1
  • 2
  • 3
  • 4
  Did you graduate?
  • Yes
  • No
  • Subjects Studied and Degree(s) Received
• Trade, Business or Correspondence School
  • Name
  • City
  • State
  Years Completed
  • 1
  • 2
  • 3
  • 4
  Did you graduate?
  • Yes
  • No
  • Subjects Studied and Degree(s) Received

• Subjects of special study or research work
• Job-Related Skills (inspection experience, molding experience, lift-truck license, typing, etc.)

• Employer 1
  • Date From
  • Date To
  • Company Name
  • City
  • State
  • Salary upon leaving
  • Position
  • Reason for leaving
  May we contact this employer?
  • Yes
  • No
• Employer 2
  • Date From
  • Date To
  • Company Name
  • City
  • State
  • Salary upon leaving
  • Position
  • Reason for leaving
  May we contact this employer?
  • Yes
  • No
• Employer 3
  • Date From
  • Date To
  • Company Name
  • City
  • State
  • Salary upon leaving
  • Position
  • Reason for leaving
  May we contact this employer?
  • Yes
  • No

• Reference 1
  • Name
  • Relationship
  • Street Address
  • City
  • State
  • Zip Code
  • Phone
  • Years Acquainted
• Reference 2
  • Name
  • Relationship
  • Street Address
  • City
  • State
  • Zip Code
  • Phone
  • Years Acquainted
• Reference 3
  • Name
  • Relationship
  • Street Address
  • City
  • State
  • Zip Code
  • Phone
  • Years Acquainted

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 For all purposes below, "the Company" refers to Custom Rubber Corporation.

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 formal 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 liabilitities 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 may 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 up on the Company unless made in writing.

• Questions or Comments