Tri-State Valve & Instrument, Inc.

APPLICATION FOR EMPLOYMENT

We are committed to a policy of Equal Employment Opportunity and will not discriminate on any legally recognized basis, including but not limited to race, age, color, religion, sex, marital status, national origin, citizenship, ancestry, handicap or disability or veteran status.

Personal Background:

Last Name: First Name: Middle Initial:

Street Address:

City: State: Zip Code:

Position Applying for:

Date you can start? Salary desired?

Are you employed? Yes No If so, may we inquire of your present employer? Yes No

Ever applied to this company before? Yes No If yes, when?

Are you willing to work overtime? Yes No

U.S. Military or Naval Service: Rank:

If driving is a requirement of the job for which you are applying, do you have a current valid driver's license? Yes No If driving is a requirement of the job which you are applying, continued employment is contingent on your maintaining a current driver's license.

If a minor, can you produce the age/work certificate necessary to obtain employment? Yes No

Are you able at the time of employment, to submit verification of your legal right to work in the U.S.? Yes No Verification and completion of the I-9 form must be submitted no later than three business days after date of hire.

Have you ever been convicted of a felony which is related to the functions or qualifications of the position for which you are applying? Yes No NOTE: This question does not apply to convictions which have been sealed or expunged. A conviction record will not necessarily be a bar to employment.

If so, please fully describe the felony conviction(s) listing the nature of the offense(s) and your rehabilitation since the conviction(s).

Educational Background:

High School:  Name and location of school

Highest grade completed? 9 10 11 12 GED

Major area of study:

College:  Name and location of school

Highest grade completed? 1 2 3 4

Major area of study:

Trade, Business or Graduate school:  Name and location of school

Major area of study:

Specialized technical skills, i.e. computer programmer, language, equipment operation, special tools or machines used.

Work Experience:

(List below last four employers, starting with your present or last place of employment.) You may include in such history any verified work performed on a volunteer basis.

1. Name of employer: Address: Salary:   Position: Date from: Date to: Name of supervisor: Reason for leaving:  

2. Name of employer: Address: Salary:   Position: Date from: Date to: Name of supervisor: Reason for leaving:  

3. Name of employer: Address: Salary:   Position: Date from: Date to: Name of supervisor: Reason for leaving:  

4. Name of employer: Address: Salary:   Position: Date from: Date to: Name of supervisor: Reason for leaving:  

References:

Give the names of three persons not related to you, whom you have known at least three years.

1. Name: Address: Phone: Years known:

2. Name: Address: Phone: Years known:

3. Name: Address: Phone: Years known:

Applicant's Statement:

In submitting this application, I certify that all of the foregoing information is a complete and accurate statement of the facts and understand that if any misrepresentation, omission or falsification be discovered, it will constitute grounds for dismissal.  I hereby authorize you to conduct any investigation necessary concerning any part of my background related to the position I am seeking.  I release all parties from any liability in connection with the provision and use of such information.

I understand and agree that, if employed by this organization, I will abide by its rules and regulations which I understand are subject to change.  I further understand that, if hired, my employment is for no definite period of time and may be terminated by either party at any time.

E-mail address: