Employment Application Form

Personal Information
Date
Date Format: MM slash DD slash YYYY
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*

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Applicant's Information
Highest education level*
Do you have a driver's license?*
State*
Driver's license number*
How did you hear about employment opportunities with us?*
Position or type of for which you are applying*
Do you like math and geometry?*
Do you know anyone at Safe-Grain, Inc. or Maxi-Tronic, Inc?*
What is their name and how do you know them?*
Desired hourly wage or annual salary?*
Date which you would be available?*
Date Format: MM slash DD slash YYYY
Are you bondable?*
- Yes
- No
- I don't know
Are you a US citizen or do you have a legal right and necessary documents to work in the U.S.?*
- Yes
- No
Identity and employment eligibility of all new hires will be verified as required by the Immigration Reform and Control Act of 1986
Have you ever worked for this company?*
If YES, when?*
Have you ever been convicted of a crime other than a minor traffic violation?*
- No
- Yes
Note: Your are not obligated to discuss sealed or expunged record of conviction or arrest nor will such information be asked of you or considered in employment decisions.
If YES, please explain offense and final disposition.*
Have you been convicted of any moving (traffic) violations in the past five years?*
- No
- Yes
If YES, please explain.*

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Education
High School*
Year of high school graduation or GED completion
Name of college or university*
Undergraduate degree*
Year of graduation*
Post graduate college or universty*
Post graduate degree*
Year of post graduate degree*
Other school*
Other education received*
Year other education completed*

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References
Please list three professional references
Reference 1
Name*
First Last
Relationship*
Company*
City*
State*
Phone

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Reference 2
Name*
First Last
Relationship*
Company*
City*
State*
Phone

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Reference 3
Name*
First Last
Relationship*
Company*
City*
State*
Phone

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Employment History
Previous employer - most recent
Company*
Phone
City*
State*
Supervisor*
First Last
Job title*
Starting salary or wage*
Ending salary or wage*
Responsibilities*
From*
Date Format: MM slash DD slash YYYY
To*
Date Format: MM slash DD slash YYYY
Reason for leaving*
May we contact your previous supervisor for a reference?*
- Yes
- No
Was there another employer before this one?

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Previous Employer 2
Company*
Phone
City*
State*
Supervisor*
First Last
Job title*
Starting salary or wage*
Ending salary or wage*
Responsibilities*
From*
Date Format: MM slash DD slash YYYY
To*
Date Format: MM slash DD slash YYYY
Reason for leaving*
May we contact your previous supervisor for a reference?*
- Yes
- No
Was there another employer before this one?*

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Previous Employer 3
Company*
Phone
City*
State*
Supervisor*
First Last
Job title*
Starting salary or wage*
Ending salary or wage*
Responsibilities*
From*
Date Format: MM slash DD slash YYYY
To*
Date Format: MM slash DD slash YYYY
Reason for leaving*
May we contact your previous supervisor for a reference?*
- Yes
- No
Were you ever discharged by a company?*
- No
- Yes
Please provide the reason for discharge.*

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U.S. Military Service
Were you enlisted in the U.S. military?*
Branch*
Technical Specialization*
From*
Date Format: MM slash DD slash YYYY
To*
Date Format: MM slash DD slash YYYY
Rank at discharge*
Type of discharge
If discharge was other than honorable, explain*

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Applicant Acknowledgement and Authorization
Please read carefully before checking the box. Check the box at the bottom when you are done reading. I hereby certify that all of the information provided by me in this application (or any other accompanying or required documents) is correct, accurate and complete to the best of my knowledge. I understand that the falsification, misrepresentation or omission of any facts in said documents will be cause for denial of employment or immediate termination of employment regardless of the timing or circumstances of discovery. I understand that submission of an application does not guarantee employment. I further understand that, should an offer of employment be extended by Safe-Grain/Maxi-Tronic that such employment with Safe- Grain/Maxi-Tronic is at will, for no specified duration and may be terminated by either Safe-Grain/Maxi- Tronic or myself at any time, with or without cause or notice. I understand that none of the documents, policies, procedures, actions, statements of Safe-Grain/Maxi-Tronic or its representatives used during the employment process is deemed a contract of employment real or implied. I understand that no representative of Safe-Grain/Maxi-Tronic except the President has the authority to enter into any agreement guaranteeing any conditions of employment or any agreement contrary to the foregoing statements and that any such agreements must be made in writing and signed by the President of Safe-Grain/Maxi-Tronic. In consideration for employment with Safe-Grain/Maxi-Tronic, if employed, I agree to conform to the rules, regulations, policies and procedures of Safe-Grain/Maxi-Tronic at all times and understand that such obedience is a condition of employment. I understand that due to the nature of Safe-Grain/Maxi-Tronic business, attendance and punctuality are considered essential requirements of every job at Safe-Grain/Maxi- Tronic and that poor attendance or tardiness will result in disciplinary action. I understand that if offered a position with Safe-Grain/Maxi-Tronic, 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 pre-employments tests and checks will result in withdrawal of any employment offer or termination of employment if already employed. I understand that due to the nature of the business Safe-Grain/Maxi-Tronic requires a well-groomed appearance and the covering of body art/wording, or covering/removing body and facial piercings when in view of customers. I understand that due to safe manufacturing practices, Safe-Grain/Maxi-Tronic prohibits the wearing of items that can potentially cause a hazardous situation for the employee or others, including chains, excessively long necklaces and hair longer than shoulder length, which if longer than shoulder length must be tied back for safety. I herby authorize any and all schools, former employers, references, courts and any others who have information about me to provide such information to Safe-Grain/Maxi-Tronic and/or any of its representatives, agents or vendors and I release all parties involved from any and all liability for any and all damage that may result from providing such information.
Acknowledgement
BY CHECKING "YES" BELOW I ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ABOVE STATEMENT
Do you agree to the above terms?*
- No
- Yes

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NOTICE TO APPLICANT AND AUTHORIZATION FOR CONSUMER REPORT
Check the box at the bottom when you are done reading. The purpose of this notice is to inform you that we will be conducting a pre-employment background investigation in conjunction with your application for employment with our company. This background investigation may involve verifying or reviewing any of the following relevant information: o Social Security Number o DVM Record o Criminal Convictions o Prior Employment History o Educational History As part of this investigation, Safe-Grain/Maxi-Tronic will obtain a consumer report from a Consumer Reporting Agency, (insert name of Agency), for employment purposes. A copy of the report will be provided to you, free of charge, if you wish. By your signature below, you authorize Safe-Grain/Maxi-Tronic to obtain this consumer report. This notice and authorization is in accordance with the Fair Credit Reporting Act.
Authorization
I authorize Safe-Grain/Maxi-Tronic to obtain a consumer report for employment purposes.
Do you agree to the above?*
- No
- Yes
Would you like a copy of your report?*
- Yes
- No

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Confirmation
eSignature - Please read the following statement carefully, then acknowledge that you have read and approved it by providing the information requested at the bottom of the page. Please note that an esignature is the electronic equivalent of a hand-written signature. I hereby state and acknowledge that the information provided is true and complete to the best of my knowledge and agree that any inaccurate and misleading information or significant omissions may disqualify me from further consideration for employment with Safe-Grain, Inc. and Maxi-Tronic, Inc. Do Not E-Sign Until You Have Read The Above Statement.
By my eSignature below, I certify that I have read, fully understand and accept all terms of the foregoing statement. Please signify your acceptance by entering the information requested in the fields below. Please enter your full name:*
First Last
Please enter your identifier - your first initial and the last four digits of your phone number.*
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Maxi-Tronic

Employment Application Form

Employment Applications

Step 1 of 13

Personal Information

Applicant's Information

Education

References

Reference 1

Reference 2

Reference 3

Employment History

Previous employer - most recent

Previous Employer 2

Previous Employer 3

U.S. Military Service

Applicant Acknowledgement and Authorization

Acknowledgement

NOTICE TO APPLICANT AND AUTHORIZATION FOR CONSUMER REPORT

Authorization

Confirmation