Application for Employment, New Bedford, MA

An Equal Opportunity Employer

Personal Information

First Name *

Last Name *

Present Address *

City *

State *

Zip Code *

Email Address *

Phone

Cell Phone

Position Applying For: *

Education

High School *

City, County & State *

0/50 characters

Did You Graduate? *

Yes

GED

Undergraduate College

City, State

0/50 characters

Area of Study

Degree/Certification/Diploma

Other Schools, Special Training and Skills

Employment History

Employer 1 (most recent)

Company Name

Address

Phone

Start Date +

End Date +

Starting Position

Ending Position

Supervisor/Manager

Reason for Leaving

May we contact? *

Yes

Employer 2

Company Name

Address

Phone

Start Date +

End Date +

Starting Position

Ending Position

Supervisor/Manager

Reason for Leaving

May we contact?

Yes

Employer 3

Company Name

Address

Phone

Start Date +

End Date +

Starting Position

Ending Position

Supervisor/Manager

Reason for Leaving

May we contact?

Yes

US Military Service

Have you served in the US armed forces?

Yes

If yes, please list any special training you received while in the service:

General Infomation

Have you ever been granted a security clearance? *

Yes

If yes, indicate level of clearance, date granted and where:

Has clearance ever been refused or revoked?

Yes

Do you have any impairment, physical, mental or medical which would interfere with your ability to perform the job for which you are applying? *

Yes

If yes please describe:

Are you a US citizen? *

Yes

If no, do you have a work permit?

Yes

References (do not use relatives)

Reference 1

Name

Title

Email Address

Phone

Reference 2

Name

Title

Email Address

Phone

Reference 3

Name

Title

Email Address

Phone

Please submit a copy of your resume.

As a Condition of Employment I agree to the Following

1. I understand that I will be required to pass a pre-employment physical including drug screening. The cost of the physical will be paid by Cornell Dubilier.

2. My employment will be governed by the policies and procedures as set forth in my employer's policy manuals and documents, as these policies and practices have been construed and applied by my employer, and which are subject to modification by my employer without notice. My employment may be terminated by me or my employer at any time.

3. Except as required in the performance of my duties for Cornell Dubilier, I will never use or disclose to others information or data that is confidential to my employer, i.e., information that is not generally available pertaining, but not limited to research, development, manufacturing, purchasing, financial accounting, engineering, marketing, merchandising and selling activities. I also agree that all papers, keys, identification cards, credit cards, tools, equipment or other property furnished by my employer or which I prepared or made, in whole or in part, at any time while employed by my employer, shall be the property of my employer and upon its request or the termination of my employment, I will promptly surrender such property to my employer.

4. I authorize an investigation of any matters referred to in this application and authorize all persons and firms listed herein to provide information about me as requested, and they are hereby released from all liability for furnishing information. I also understand that errors or omissions on matters covered by this application will be sufficient cause for dismissal from employment.

I have read, understood and signed the above agreement. *

clear

Date +