327 E. LaSalle Street

Somonauk, IL 60552

(815) 498-2303

imperialmarblecorp.com

Application For Employment

PERSONAL INFORMATION

NAME

LASTFIRSTMIDDLE

ADDRESS

STREETCITYSTATEZIP

PHONE NUMBERSOCIAL SECURITY NUMBER

IF HIRED, CAN YOU PROVIDE PROOF OF ELIGIBLITY TO WORK IN THE U.S. ?  YES  NO

HAVE YOU EVER BEEN CONVICTED OF A FELONY OFFENSE?  YES  NO

IF YES, PLEASE DESCRIBE: ______

You will not be denied employment solely because of a conviction record, unless the offense is related to the job for which you have applied.

EMPLOYMENT DESIRED

POSITIONDATE YOU CAN STARTSALARY DESIRED

ARE YOU EMPLOYED NOW?IF SO MAY WE INQUIRE OF YOUR PRESENT EMPLOYER?

HAVE YOU EVER WORKED FOR THIS COMPANY BEFORE YES NO

HAVE YOU EVER BELONGED TO A UNION? YES NO

CAN YOU SPEAK ENGLISH? YES NO

ARE YOU ABLE TO WORK ANY SHIFT? YES NO

DO YOU HAVE A VALID DRIVER’S LICENSE? YES NO

ARE YOU WILLING TO TAKE A PRE-EMPLOYMENT DRUG TEST? YES NO

DO YOU HAVE THE ABILITY TO LIFT 50 POUNDS? YES NO

EDUCATION

EDUCATION / NAME AND LOCATION OF SCHOOL / YEARS
ATTENDED (FROM – TO) / *DID YOU GRADUATE? / SUBJECTS STUDIED
HIGH SCHOOL
COLLEGE
TRADE,BUSINESS/ CORRESPONDENCE SCHOOL

* The age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age.

FORMER EMPLOYERS (LIST BELOW LAST FIVE EMPLOYERS, STARTING WITH LAST ONE FIRST)

NAME AND ADDRESS OF PRESENT OR LAST EMPLOYER

STARTING DATELEAVING DATE

MONTHYEAR MONTHYEAR

STARTING SALARY/WAGESENDING SALARY/WAGES

JOB TITLEMAY WE CONTACT SUPERVISOR?

NAME / TITLE OF SUPERVISORPHONE #

DESCRIPTION OF WORK

REASON FOR LEAVING

NAME AND ADDRESS OF PRESENT OR LAST EMPLOYER

STARTING DATELEAVING DATE

MONTHYEAR MONTHYEAR

STARTING SALARY/WAGESENDING SALARY/WAGES

JOB TITLEMAY WE CONTACT SUPERVISOR?

NAME / TITLE OF SUPERVISORPHONE #

DESCRIPTION OF WORK

REASON FOR LEAVING

NAME AND ADDRESS OF PRESENT OR LAST EMPLOYER

STARTING DATELEAVING DATE

MONTHYEAR MONTHYEAR

STARTING SALARY/WAGESENDING SALARY/WAGES

JOB TITLEMAY WE CONTACT SUPERVISOR?

NAME / TITLE OF SUPERVISORPHONE #

DESCRIPTION OF WORK

REASON FOR LEAVING

REFERENCES: GIVE THE BELOW NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR

NAME / ADDRESS AND PHONE / BUSINESS / YEARS ACQUAINTED
1.
2.
3.

AUTHORIZATION

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed; falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise and release all parties from all liability for any damage that may result from furnishing same to you.

I agree to provide consent for the company to conduct appropriate background checks.

I also understand that, if hired, I am required to abide by all rules, ordinances, and regulations of the company. The company policies and procedures relating to conditions of employment are subject to modification without notice.

DateSignature

Effective February 2014