Index

Contract Type Full Time Part Time Temporary

Start Date Position Applying For Name Birthday Email Address Address Phone City / State / Zip

Have you ever been convicted of or charged with a felony or misdemeanor Yes No

If yes, please explain the details in full, including dates, details of offense(s) charged, jurisdiction and disposition of case

Have you, or any person or entity with whom you have been associated with, filed for bankruptcy, been declared bankrupt or insolvent or been the subject of any receivership proceedings within the last 7 years? Yes No

If Yes, please provide full details, including dates, places, amounts involved and disposition

Schools / Colleges Attended

# Years

Year Grad

Degree

Start with your present or most recent position. Include military service assignments and volunteer activities. Exclude organization names that indicate race, color, religion, sex or national origin.

Employer 1

Employer Job Title Supervisor Street Address City / State / Zip Phone Duties / Responsibilities / Accomplishments Reason for Leaving Date of Employment (Month / Year) to

Add another?

Business References

Please provide individual and company names, position, addresses and phone numbers for 3 business references.

Business Reference 1

Name Company Street Address Position City / State / Zip Phone

Add another?

Personal References

Please provide names, addresses, phone numbers, relationship and how long known for 3 personal references.

Personal Reference 1

Name Company Street Address Position City / State / Zip Phone

Add another?

Describe any special skills or qualifications for this work

How lucky do you consider yourself to be on a scale 1—10? 1 ‐ "I don't know why but bad things always seem to happen to me"
2
3
4
5 ‐ "I'm about as lucky as the average person."
6
7
8
9
10 ‐ "I don't know why but good things always seem to happen to me"

If you could be a super hero who would you be and why?
If you entered a room and a theme song played, what would be your song and why?
If you could invite any two people to lunch, who would you invite and why? (from the past or present, real or fictional)

I CERTIFY that the above answers are true and complete to the best of my knowledge. I authorize, A&C Plastics to investigate any statement contained in this application, and to obtain a credit report on me (and my company if this application is for reselling by a company) as necessary to determine my qualifications. I understand that this application is not and is not intended to be any kind of contract or agreement. In the event of employment, I understand that any false or misleading information given in my application, correspondence, discussions or interview may result in immediate termination. I understand also, that I am required to abide by all rules, regulations and policies of A&C Plastics.

Signed Date

Apply to Work With A&C Plastics

Employer 1

Business References

Business Reference 1

Personal References

Personal Reference 1