Employment Application

Personal Information

Name / Date
Last First MI
Address /
Street City State Zip Code
Home phone # / Cell phone #
E-mail address /

Are you 18 years of age or older? ☐Yes☐No

Are you either a U.S. citizen or an alien authorized to work in the U.S.? ☐Yes ☐No

Have you ever been convicted of a felony?* ☐Yes ☐No

If yes, give details, including date(s): ______

*Answering "yes" will not automatically disqualify you from employment. We will consider the nature and date of the offense and the job for which you are applying for job-related purposes only, and only to the extent permitted bylaw.

Position Desired

Position / Date available to start
Do you prefer / ☐ / Full-time / ☐ / Part-time / Desired pay range
If part-time, what hours/days are you available
Have you previously worked for ACD? / ☐ / Yes / ☐ / No
If yes, when? / Reason for leaving
How did you learn about this opening? / Internet /

Education

Name/City/State / Graduated? / Degree received / Subject studied/Major
High School/GED / ☐Yes ☐No / n/a / n/a
Technical School / ☐Yes ☐No
College/University / ☐Yes ☐No /
Awards/Certifications/Other

Work Experience

Please list previous employment, beginning with the most recent. If you need more room, attach another sheet of paper. Incomplete information could disqualify you from further consideration.
Employer / Address and phone:
From(mo/yr) To(mo/yr) / Position held / Reason for leaving
Supervisor name, title and phone number / May we contact? ☐Yes ☐No
Was(is) this position: Part-time ☐ Full-time ☐ / Beginning compensation
Duties / Ending compensation
Employer / Address and phone:
From(mo/yr) To(mo/yr) / Position held / Reason for leaving
Supervisor name, title and phone number / May we contact? ☐Yes ☐No
Was(is) this position: Part-time ☐ Full-time ☐ / Beginning compensation
Duties / Ending compensation
Employer / Address and phone:
From(mo/yr) To(mo/yr) / Position held / Reason for leaving
Supervisor name, title and phone number / May we contact? ☐Yes ☐No
Was(is) this position: Part-time ☐ Full-time ☐ / Beginning compensation
Duties / Ending compensation
Employer / Address and phone:
From(mo/yr) To(mo/yr) / Position held / Reason for leaving
Supervisor name, title and phone number / May we contact? ☐Yes ☐No
Was(is) this position: Part-time ☐ Full-time ☒ / Beginning compensation
Duties / Ending compensation

Professional References

List at least 3 people that you have worked with and include at least 1 supervisor.

Name and title/position / Phone # and/or e-mail / Relationship to you

Military Service

Branch / From / To
Rank at discharge / Type of Discharge
If other than honorable, please explain

Authorization and Acknowledgements

Please read carefully before signing:

I understand that ACD Distribution, LLC (ACD) is an equal opportunity employer. ACD does not discriminate based upon race, color, religion, national origin, citizenship, ancestry, age (over 40), gender, sexual orientation, pregnancy, marital status, physical or mental disability, medical condition, gender identity or expression, genetic information including sickle cell or hemoglobin C trait, military or veteran status, or any other consideration made unlawful by applicable federal, state, or local law.

I affirm that the information I have provided in this application is true to the best of my knowledge and belief, and I have not knowingly withheld any information requested. I authorize the company to verify my references, record of employment, education record, and any other information I have provided.

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for ACD to hire me. If I am hired, I understand that employment is at will, and that either ACD or I can terminate my employment at any time and for any reason, with or without cause, and without prior notice. I understand that no representative of ACDhas the authority to make any assurance to the contrary.

Signature / Date signed

ACD Distribution, 3129 Deming Way, Middleton, WI 53562pg. 1 of 3 – Employment Application

Last revision date 10/3/2013