Employment Application - Jergens Piping

Applicant Information

Name*

First Middle Last

Email*

Enter Email Confirm Email

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Length of time at current address*

How long have you lived in your current city?*

Are you 18 years of age or older?*

Yes
No

Are you authorized to work in the United States?*

Yes
No

Position(s) Applied for

Division you are applying to*

Which division are you interested in working with?

Job you are applying for (first choice)*

Rate of pay expected per hour*

Job you are applying for (second choice)

Not required

Rate of pay expected per hour

Would you like to work*

Full-time
Part-time

Date available to begin work*

If part time, what days and hours?*

Have you ever applied for work with us before?*

No
Yes

If yes, when?*

List anyone you know who works for us

Skills, qualifications, or experience related to working with us*

U.S. Armed Forces Service

Have you served in a branch of the U.S. Military?*

Yes
No

Please indicate which branch*

Rank at time of enlistment*

Rank at time of discharge*

Type of discharge*

Honorable
Dishonorable

If dishonorable, please explain*

Education

Highschool attended*

Number of years attended*

Address*

City State / Province / Region Country

Did you attend college*

Yes
No

College name*

Address*

City State / Province / Region Country

Course or degree*

Did you graduate?*

Yes
No

Did you attend another type of school?*

Yes
No

School name*

Address*

City State / Province / Region Country

Course or degree*

Did you graduate?*

Yes
No

Prior Work Experience

Please list your most recent employment first, use additional space below if necessary to list additional employers.

Previous Employer's Name

Employer's Address

Street Address Address Line 2 City State ZIP Code

Begin Date

End Date

Type of work performed

Starting pay

Final pay

Reason for leaving

Employer 2

Previous Employer's Name

Employer's Address

Street Address Address Line 2 City State ZIP Code

Begin Date

End Date

Type of work performed

Starting pay

Final pay

Reason for leaving

Employer 3

Previous Employer's Name

Employer's Address

Street Address Address Line 2 City State ZIP Code

Begin Date

End Date

Type of work performed

Starting pay

Final pay

Reason for leaving

Business References

List only those persons who held managerial positions in the company you were employed at during the time of your employment.

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Occupation

Reference 2

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Occupation

Reference 3

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Occupation

Reference 4

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Occupation

1. Certification of truthfulness*

I agree

I certify that all statements on this Application for Employment are complete and truthful and agree that such statements may be investigated and if found to be false will be sufficient reason for not being employed and may result in my dismissal.

2. Authorization for employment & educational information*

I agree

I authorize the references listed in this Application for Employment, and any prior employer, educational institution, or any other persons or organizations to give this Company any and all information concerning my previous employment / education accomplishments, disciplinary information or any other pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you. I hereby waive written notice that employment information is being provided by any person or organization.

3. Employment at will*

I agree

If I am hired, in consideration of my employment, I agree to abide by the rules and policies of this Company, including any changes made from time to time, and agree that my employment and compensation can be terminated with or without cause, and with or without notice, at any time, at the option of either the Company or myself. I understand that no manager or other representative of the Company, other than the President, has any authority to enter into any agreement for employment for any specific or indefinite period of time, or to make any agreement contrary to the foregoing. Any such agreement made by the President must be made in writing to be effective.

4. Authorization to work*

I agree

If I am selected for hire, I will be offered employment provided I verify that I am authorized to work as required by the Immigration Reform and Control Act of 1986.

5. Need for accommodation*

I agree

If I have a mental or physical disability and require an accommodation to perform the job, I must notify the Company of that need in writing within 182 days after I know or reasonably should have known that an accommodation was needed. Failure to do so will bar me from alleging that the Company has not accommodated me as required by law.

6. Criminal records check*

I agree

I authorize the Company to secure my criminal conviction history. I agree to execute the appropriate authorization if necessary to obtain such information.

7. Drug and alcohol testing*

I agree

Following a conditional job offer, I also authorize Jergens or its designated agent(s) to withdraw specimen(s) of my blood, urine, hair and/ or other substances for chemical analysis. One purpose of this analysis is to determine or exclude the presence of alcohol, drugs or other substances. I understand that decisions concerning my employment may be made as a result of these tests. b. I agree and understand, upon acceptance of an offered position with Jergens, the offer is contingent upon successful results from a background check and drug testing. If I decide not to join Jergens after the background check and drug testing have been Completed, I agree and understand I am responsible for these cost incurred on my behalf and will reimburse Jergens immediately.

8. Consideration For Employment*

I agree

a. I understand that my application will be considered pursuant to the Company's normal procedures for a period of thirty (30) days. If I am still interested in employment thereafter, I must reapply. b. I agree that if any of the above commitments is ever found to be legally unenforceable as written, the particular commitment concerned shall be limited to allow its enforcement as far as legally possible. c. I have read, understand, and agree to items 1 through 8 above. I knowingly and voluntarily acknowledge that with my signature (in typed format) below.

Signature*

Please type your full name as your signature

Today's date*

Emergency Contact Information

Name

Relationship

Primary phone

Secondary phone

Other phone

Name

This field is for validation purposes and should be left unchanged.