Your Name (required)
Your Email (required)
Emergency Contact Phone
Are you 18 years of age or older YesNo
If under age 18, can you, after employment, submit a work permit? YesNo
Have you filed an application before? YesNo
If you have applied before, give dates.
Have you ever been employed here before? YesNo
If you have been employed here before give dates.
Are any of your relatives current or former employees of the Company? YesNo
If yes, identify.
Are you employed now? YesNo
If so may we contact your current employer? YesNo
Are you on a lay-off and subject to recall? YesNo
What days and hours are you available to work? YesNo
On what date would you be able to start.
If applying for part-time work, specify hours desired by day and time.
The job for which you are applying may require work on Saturdays, Sundays, holidays and evenings and substantial travel. If so, are you willing to work such a schedule. YesNo
If hired, can you provide the documents required by law to prove that you are legally able to work in the U.S.? YesNo
Have you ever been convicted of a felony? YesNo
If yes, explain. NOTE: A criminal conviction is not necessarily a bar to employment, factors such as your age at the time, nature of the offense, and completion of rehabilitation will be taken into consideration.
Is there any reason your prompt and regular attendance at work will be affected? YesNo
If yes, describe.
Has an employer for other than lack of work ever terminated you? YesNo
Can you perform the functions of the job for which you are applying (essential and/or marginal), without accommodation? YesNo
Education, High School name and location?
High school G.P.A.?
High school diploma or certificate?
Technical training, name of school and or trade?
Technical training, degree, diploma or certificates received?
College name and location?
Employer training name and location?
Employer training subject?
Employer training degree, diploma and or certificate?
Other, list all training and certificates applicable?
Employer 1, Please list: DATES EMPLOYED - START / END EMPLOYER NAME, ADDRESS and PHONE NUMBER SUPERVISOR'S NAME and TITLE, and REASON FOR LEAVING POSITION SALARY - START / END
Employer 2, Please list: DATES EMPLOYED - START / END EMPLOYER NAME, ADDRESS and PHONE NUMBER SUPERVISOR'S NAME and TITLE, and REASON FOR LEAVING POSITION SALARY - START / END
Employer 3, Please list: DATES EMPLOYED - START / END EMPLOYER NAME, ADDRESS and PHONE NUMBER SUPERVISOR'S NAME and TITLE, and REASON FOR LEAVING POSITION SALARY - START / END
Employer 4, Please list: DATES EMPLOYED - START / END EMPLOYER NAME, ADDRESS and PHONE NUMBER SUPERVISOR'S NAME and TITLE, and REASON FOR LEAVING POSITION SALARY - START / END
Summarize special skills and qualifications acquired from employment or experience.
What languages can you read, write and speak fluently?
What licenses or certifications do you have or have had?
Licenses or Certifications
What professional associations do you belong to?
OFFICE SKILLS (Typing words per minute)
OFFICE SKILLS (Shorthand words per minute)
CAREER OBJECTIVES, Describe your career and income objectives, and how your employment with the Company fits those objectives.
REFERENCES, Give the name of three persons not related to you, whom you have known at least one year.
REFERENCE 1, Include: Name Address & Phone Employer & Title Years Acquainted
REFERENCE 2, Include: Name Address & Phone Employer & Title Years Acquainted
REFERENCE 3, Include: Name Address & Phone Employer & Title Years Acquainted
I HAVE READ CARFULLY AND AGREE TO THE ACKNOWLEDGEMENTS, RELEASE OF CLAIMS AND OTHER IMPORTANT INFORMATION* I certify that the information above and/or other information I furnish you is true and complete to the best of my knowledge. I understand that the firm may investigate my work and personal history and verify all data given on this application, on related papers, and in interviews, but that it is not required to do so. I authorize all individuals, schools and employers named and all financial institutions, law enforcement agencies and other persons, except as specifically limited on this application, to provide information requested about me, and I release them from liability for damages in providing this information. I understand and acknowledge that any misrepresentation or omission of fact by me can result in immediate discharge.I understand and acknowledge that, if employed, my employment and compensation will be at the will of Cotterman Company / Conveyor Components Company and can be terminated, with or without cause, and with or without notice, at any time at my option or the option of Cotterman Company / Conveyor Components Company. I further understand and agree that no officer, manager, or employee of the Company other than it's President has now or has had in the past any authority to enter into any agreement for employment for any specified period of time or to make any agreement which is contrary to or a modification of the above described employment relationship, and that any such agreement or representation must be in writing and signed by myself and the President of Cotterman Company / Conveyor Components Company.I consent to random drug testing and searches of my personal property on the Company's premises, at the Company's expense. I understand a refusal to take a test on request may result in a proper termination of the application process or my employment. All applicants being considered for employment may be tested for the following drugs or their metabolites:AMPHETAMINE - Uppers/SpeedBARBITURATES - Sleeping PillsBENZODIAZ - ValiumOPIATE - Heroin/CodeineMETHADONE - Heroin AddictsCOCAINE - Crack/CocaineMETHAQUALONE - Quaalude's/Sleeping PillsPHECYC-PCP - Animal TranquilizerPROPAXYPHENE - DarvonCANNABINOID-THC - MarijuanaI authorize the medical clinic/testing laboratory to release any test results to the Company and the Company to use them as a determining factor in the selection and retention of employees. Applicants offered positions may be required to pass a job-related physical examination before beginning work. I authorize release of examination results to the Company.If I am applying for a position in Michigan, I acknowledge that if I am disabled and require an accommodation to enable me to perform a job, under Michigan law, I must notify the Company of such an accommodation, in writing, within 182 days of when I knew or should have known of such a need, or I will be unable to rely on the Company's statutory duty under Michigan law to accommodate, if any.
ELECTRONIC SIGNATURE FOR ACKNOWLEDGEMENT*
By selecting the "Submit" button, you are confirming that you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Online Application. By selecting "Submit" using any device, means or action, you consent to the legally binding terms and conditions of this document. You further agree that your signature on this document (hereafter referred to as your "Electronic Signature ") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your Electronic Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your signature or any resulting agreement between you and the Company.
PLEASE READ This application will only be considered for the 1 year period after its receipt by Cotterman Company / Conveyor Components Company. Should you wish to be considered after the expiration of this period, you must reapply. Cotterman Company / Conveyor Components Company is an equal opportunity employer and complies with all laws prohibiting discrimination on the basis of race, color, age, sex, national origin, religion, citizenship, disability, height, weight and marital status.