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.



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