EMPLOYMENT APPLICATION

* Indicates Required Field

Position Applied For:

Referred by:

Date:
(dd/mm/yyyy)

* Name:

* Telephone:

Address:

City:

State:

Zip Code:

Social Security #:

* Email:

Are you a U.S. Citizen or otherwise authorized to work in the U.S.?
Yes No

Are you over the age of 18?
Yes No

If under 18, date of birth:

Have you ever been convicted of a felony?
Yes No

If yes, explain:

Have you been employed at NEI GLASS before?
Yes No

If yes, give dates, position:

EMPLOYMENT RECORD (list most recent job first)

If currently employed, may we contact your present employer?
Yes No

1. Name of Company:

Address:

Telephone:

Supervisor:

Position:

Reason for Leaving:

Starting Salary:

Ending Salary:

Dates of employment:

From:

To:

2. Name of Company:

Address:

Telephone:

Supervisor:

Position:

Reason for Leaving:

Starting Salary:

Ending Salary:

Dates of employment:

From:

To:

3. Name of Company:

Address:

Telephone:

Supervisor:

Position:

Reason for Leaving:

Starting Salary:

Ending Salary:

Dates of employment:

From:

To:

Is there anything else you would like to include as additional information?

DRIVING RECORD

Do you have a valid drivers license?
Yes No

State:

License Number:

Has your license ever been suspended or revoked?
Yes No

If yes, please explain:

Do you have any DUI or DWI convictions?
Yes No

If yes, please state when you were convicted and explain:

I certify that the answers above are true and correct to the best of my knowledge. I give NEI GLASS, Inc. permission to verify this information, and release all persons, including NEI GLASS, Inc. and its affiliates with respect to any information provided by prior employers or personal references. I acknowledge that if any information in this application is untrue, I may be terminated. I understand that if I am employed, my continued employment is at all times subject to the policies and procedures established by NEI GLASS, Inc. from time to time, and that my employment may be terminated at any time by me or by NEI GLASS, Inc. with or without cause. I understand that any offer of employment to me is conditioned upon my furnishing all documents required by law to be furnished to an employer, and my ability to perform all of the essential elements of my job with reasonable accommodation.