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Employment Application Form

Please fill out the entire form below and submit to our Human Resource Department. You will be contacted promptly.
 
AN EQUAL OPPORTUNITY EMPLOYER
Federal and/or state laws prohibit discrimination based on age; sex; national origin; religion; marital; veteran or handicap status.
(*) DENOTES REQUIRED FIELD
PERSONAL HISTORY      
*Name
  (First) (Middle) (Last)
*Phone *E-mail
*Address
 
  (City) (State) (Zip)
*SSN    
*Have you ever worked or attended school under another name?
 
If yes, please provide that name:
Name
  (First) (Middle) (Last)
*Do you have a valid Driver’s License?
  If Yes, in which state?
*Are you under 18 years old?
  If Yes, please attach a copy of your work permit.
*Are you either a U.S. Citizen or Permanent Resident?
 
If No, Please answer the following:
Do you have the legal right to work?
 
Visa Type: B1 F1 H1 J1 L1
Other:    
*Position Desired *Years Related Experience
*What prompted you to apply at Lightronics, Inc.?
  Newspaper Ad Agency Other - Specify Below
  Employee Referral By Lightronics Website
*Do you have relatives employed at Lightronics, Inc.?
  If Yes, please give their name(s):
*What hours do you prefer to work?
  Full-time Part-time  
*Are there certain days of the week that you cannot work?
  Yes, list days
*Can you work overtime?
     
*Do you have a condition which may limit your ability to perform the job(s) applied for?
     
If Yes, what can be done to accommodate you?  
*Have you ever been convicted of a felony?
     
If Yes, give date, place, offense and outcome.
(Previous convictions do not exclude an applicant from consideration for employment.)
 
     
EMPLOYMENT HISTORY
Please list in chronological order all of your work history over the last 10 years, beginning with your most recent
job. Information provided on this application may be verified. Please complete even if you have submitted a
resume.
Employer Employed (from/to)
City, State Ending Base Yearly Salary $
Supervisor's Name Supervisor's Phone
Other Compensation Your Job Duties
Reason for Leaving Shift Premium $
May we contact your present employer?  
       
Employer Employed (from/to)
City, State Ending Base Yearly Salary $
Supervisor's Name Supervisor's Phone
Other Compensation Your Job Duties
Reason for Leaving Shift Premium $
May we contact your present employer?  
       
Employer Employed (from/to)
City, State Ending Base Yearly Salary $
Supervisor's Name Supervisor's Phone
Other Compensation Your Job Duties
Reason for Leaving Shift Premium $
May we contact your present employer?  
       
Former Employer Employed (from/to)
Your Position or Title Reason for Leaving
       
Former Employer Employed (from/to)
Your Position or Title Reason for Leaving
       
EDUCATION      
Did you graduate from high school or pass an equivalency exam?
     
Please list any college or vocational training in the fields below.
School (Name & Location) Degree/Certificate Granted?
Level or Type Dates Attended (from/to)
       
School (Name & Location) Degree/Certificate Granted?
Level or Type Dates Attended (from/to)
       
School (Name & Location) Degree/Certificate Granted?
Level or Type Dates Attended (from/to)
       
REFERENCES      
Please list three job or professional references.
 
  Name Title Phone
       
 
  Name Title Phone
       
 
  Name Title Phone
       
PLEASE READ THE FOLLOWING CAREFULLY BEFORE SIGNING
I understand that Lightronics, Inc. is a drug-free work place and state that I do not abuse drugs, alcohol or
restricted substances.

I also understand Lightronics, Inc. needs to verify statements on certain information about me to evaluate my
qualification for employment and to conduct its business if I become an employee. Therefore, I authorize
Lightronics, Inc. to investigate my past employment, educational credentials, and other employment related
statements and activities. I agree to cooperate in such investigations and release those parties supplying
information to Lightronics, Inc. from all liability or responsibility with respect to the information supplied.

I understand that should I be hired, any false answers or statements made by me on this application, and any
supplement thereto, or in connection with the above mentioned investigations may result in immediate discharge.
       
*Electronic Signature *Date
  Please type your First and Last name.  
       
 I understand that checking this box constitutes a legal signature confirming that I
acknowledge and agree to the above Terms of Acceptance.
       
   
       
  Privacy Policy    
       
      EEAPP.DOC 080807

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