Application Old PERSONAL INFORMATION Name: Social Security # Phone: Address: City: State: Zip: DESIRED EMPLOYMENT Position: Full TimePart Time Have you been given a copy of the job requirements? : YesNo REFERRED BY (employee’s name): EDUCATION High School: Did you graduate?YesNo Trade School: Did you graduate?YesNo College: Did you graduate?YesNo Graduate School: Did you graduate?YesNo Special Skills FORMER-CURRENT EMPLOYERS(List from most recent employer first) Company Name: May we contact?YesNo Address: Supervisor: Phone: Start Date: Leave Date: Final Wage Rate: $ Reason for Leaving: Company Name: May we contact?YesNo Address: Supervisor: Phone: Start Date: Leave Date: Final Wage Rate: $ Reason for Leaving: Company Name: May we contact?YesNo Address: Supervisor: Phone: Start Date: Leave Date: Final Wage Rate: $ Reason for Leaving: EMERGENCY PHONE NUMBERS Name: Phone: Relation: REFERENCES(Other than family, current employees or prior employers) Name: Address: Phone: Years Known: Have you been convicted of a criminal offense within the last five (5) years? : YesNo If yes, explain: ACKNOWLEDGEMENT OF APPLICATION AND EMPLOYMENT CONDITIONS I have read the requirements of the position, and I declare that I am physically able to conduct the work required without any hazard to my health. I am aware that if I am offered employment and fail any required physical examinations, prior to or after employment, that the offer may be rescinded or I may be terminated without further notice. I am also aware that Bigger Glass Company, LLC is a drug free employer and that I am required to submit to drug-alcohol screening, prior to being approved to start work. I understand that falsification or the omission of any material information required to evaluate your application for employment will be grounds for refusal to hire or for termination if the falsity or omission is discovered after employment. I declare that the information presented in this application is true. I understand that company benefits are only available to full time employees, and that they are only offered after the completion of a new hire 3 months (90 days) probationary period. The availability of any benefits offered are subject to the insurance provider’s rules and regulations. If employed, I agree to abide by the provisions established in the various company policies and procedures manuals, and all revisions, as they have been provided to me as a function of my interview process. I am aware that my employment with the company, if hired, is at will and that I, or the company, may terminate the employment relationship at any time for any reason. Finally, I understand that any negotiation or offer discussed with the interviewing manager is not valid until approved by the President or Vice President of Bigger Glass Company. Signed: Date: DRUG TESTING CONSENT AND RELEASE FORM I hereby consent to submit to a drug and alcohol screen as part of the application process, and/or as a function of my continued employment. I agree that a Bigger Glass Company appointed physician or clinic will collect these specimens for these tests and will forward them to a testing laboratory designated by the company for analysis. I further agree to and hereby authorize the release of the results of the drug and alcohol screen to Bigger Glass Company. I understand that a positive test result will prohibit my employment by Bigger Glass Company. I further agree to hold harmless Bigger Glass Company, LLC and its agents (including the company-chosen physician or clinic) from any liability arising in whole or part out of the collections of specimens, testing, and use of the information from said testing in connection with the company’s consideration of my employment application. I further agree that a reproduced copy of this pre-employment consent and release form shall have the same force and effect as the original. I have carefully read the foregoing and fully understand its contents. I acknowledge that my signing of this consent and release form is a voluntary act on my part and that I have not been coerced into signing this document by anyone. Applicant or Employee: Printed Name: SSN: Signed: Date: Witness: Printed Name: Signature: RECORD OF TRAFFIC VIOLATIONS I, ,as of this date, have been charged with the following traffic violations over the past 5 years. Date of Violation: Type of Violation (Speeding, Reckless Driving, D.U.I., etc.): I do hereby authorize Bigger Glass Company, LLC to secure a copy of my 5 year driving record. I understand that my 5 year driving record must be submitted to Bigger Glass Company’s insurance carrier for approval prior to any offer of employment being validated. I further agree that if hired by Bigger Glass Company, I will advise my supervisor immediately, in writing, of any additional violations with which I am charged. I realize the failure to do so may result in my immediate termination. I further understand that Bigger Glass Company’s insurance carrier reviews employee driving records annually, and that if at any time during an annual review of my driving record is such that it precludes me from being covered by Bigger Glass Company’s insurance carrier, this will result in the employee’s immediate loss of company vehicle driving privileges and possible termination. DRIVER'S LICENSE # AND STATE SIGNATURE: DATE:
