Employment Application

Today's Date(Required)

Name(Required)

First Middle Last

Present Address(Required)

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

Phone (Home)

Phone (Work)

Email(Required)

Are you including your Work Ready Certificate with this application?(Required)

Emergency Contact

If necessary, as in case of emergencies, who will receive messages for you?

First Last

Phone

Relationship

Are you 18 years of age or older?(Required)

If you are not a US citizen, can you, upon employment, provide a visa or alien registration number to show eligibility to work?(Required)

Position Applying for(Required)

Date Available to Work(Required)

Where did you hear about this position?

Newspaper

Employee

Internet

Other

Which Newspaper?

Employee Name

If other, please specify?

Have you ever worked for this Company?(Required)

If Yes, when and where?

When are you willing to work?(Required)

Holiday

Weekends

Overtime

All Shifts

Full Time

Part Time

Have you ever been convicted or plead guilty or no contest to a felony crime?(Required)

If Yes, list each conviction and plea

Answering Yes to this question does not automatically bar you from consideration for employment.

Have you ever been convicted or plead guilty or no contest to a crime other than a minor traffic violation?(Required)

If Yes, list each conviction and plea

Answering Yes to this question does not automatically bar you from consideration for employment.

Do you have any relatives or friends who work for this Company currently?(Required)

If Yes, please list names and relationships

Why are you applying for work at this time?(Required)

Why do you want to work for Harbin Company, Inc.?(Required)

Previous Employment Record

List present or most recent position first. Please give an account for all previous employers.

Company Name(Required)

Address(Required)

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

Phone(Required)

Type of Business(Required)

Start Date(Required)

End Date(Required)

Pay Rate(Required)

Job Title

Immediate Supervisor

Why did you leave?(Required)

If you had the opportunity to change something about this job, what would it be?(Required)

May we contact this employer?(Required)

Add additional Employer(Required)

Yes

Company Name

Address

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

Phone

Type of Business

Start Date

End Date

Pay Rate

Job Title

Immediate Supervisor

Why did you leave?

What did you like best about this job? Why?

If you had the opportunity to change something about this job, what would it be?

May we contact this Employer?

Add additional Employer

Yes

Company Name

Address

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

Phone

Type of Business

Start Date

End Date

Pay Rate

Job Title

Immediate Supervisor

Why did you leave?

If you had the opportunity to change something about this job, what would it be?

May we contact this employer?

List additional employers below

Company

Job Title

Start Date

End Date

Educational History

Highest Grade Completed(Required)

If GED, year

Area of Interest in High School(Required)

Vocational School or Junior College?(Required)

College/School Name

Did you graduate?

Certificate received

Course of Study

College or University?(Required)

College/School Name

Did you graduate?

Degree

Major(s)

GPA

Other Schools or Training

Military Service

Were you in the Military?(Required)

Branch

Date of Entry

Date of Discharge

Rank at Discharge

Military Specialty

Special Skills/Qualifications

List all skills you possess and machine or equipment you use(Required)

i.e. forklifts, data entry terminals, etc.

Driving Record

If the job requires, do you have the appropriate valid driver's license?(Required)

Driver's License #

License Type

State of License

Do you have a CDL license?

Have you had any moving violations? Please describe

Date of last DOT physical

Did you pass the physical?

Americans with Disabilities Act

Can you perform the essential functions of the position for which you have applied, with or without an accommodation by the Company?(Required)

To be considered “qualified” under the Americans With Disabilities Act, an applicant must be able to perform the essential functions of a job with or without a reasonable accommodation. “Reasonable Accommodation” is a modification or adjustment to a job, the work environment, or the way things are usually done that enables a qualified individual with a disability to enjoy an equal opportunity. If necessary, please request a copy of the job description for the position for which you are applying. Review this description and answer the following question:

To Be Signed and Read by Applicant

It is agreed and understood that the employer or his agents may investigate the applicant’s background to ascertain any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases employers and persons named herein from all liability for any damages on account of his furnishing such information. It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigative Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living. I agree to furnish such additional information and complete such examinations as may be required to complete my employment file. I understand, as a condition of employment, a copy of my motor vehicle violations record may be obtained from the State Motor Vehicle Agency. I understand that this application is not an employment contract and that, if hired, my employment and compensation can be terminated, with or without cause, at any time at the option of either the Company or me. I understand this Company is a Drug-Free Workplace and that I will have to submit to all requirements of that program before I can be employed, including a pre-employment drug screen. This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge. I understand that if I am employed and any information I have provided is found to be false or incomplete in any respect, I will be subject to dismissal without notice.

Signature(Required)

Date(Required)

Harbin Lumber Company, Inc. Operations and Procedures Manual

An equal opportunity employer