Online Application for Employment

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TO THE APPLICANT: We appreciate your interest in the Peerless Chain Company and assure you that we are interested in you and the potential you offer. To help provide a clear understanding of your educational background, work experience, and other pertinent factors, please complete all information called for as neatly and thoroughly as possible.

No hiring or employment practice of the Peerless Chain Company in any way discriminates or tends to discriminate against any applicant or employee with regard to race, color, creed, religion, sex, national origin, age, disability, sexual orientation, marital status, eligibility for military service, citizenship status, or mental or physical handicap that does not prevent performance of essential functions of the position(s) for which I am applying as provided by state and federal law.

Conditions of employment are stated at the end of this form. Please read carefully before you sign this application. (Application must be completed in full even if attaching a resume.)

Application for Employment Position(s) applied for:

Full Time

Part Time

Section 1 Personal

First Name

Middle Name

Last Name

Present Address

Address

City

State

Zip

Phone Number

Previous Address

Address

City

State

Zip

Phone Number

If no phone, how may we contact you?

Are any relatives presently employed with the company or its divisions?	Yes	No
	If yes, where?

Have you ever worked for the company or its divisions before?	Yes	No
	If yes, when?
	where?

Have you ever applied for employment with this company or its divisions before?	Yes	No
	If yes, when?
	where?

Section 2 General Information

Are you 18 years of age or older?	Yes	No
Only U.S. citizens or aliens who have a legal right to work in the U.S. are eligible for employment. Can you, upon employment, provide genuine documentation establishing your identity and eligibility to be legally employed in the united states? (Proof of citizenship or immigration status will be required upon employment)	Yes	No
Have you been convicted of a crime or violation other than a minor traffic infraction? (A Conviction record will not necessarily be a bar to employment. Factores such as job relations, age and time of the offense, seriousness and nature of violation and rehabilitation will be taken into account)	Yes	No

If yes, please explain


Wage Expected?

On what date would you be available for work?

Section 3 Employment History

Begin with your most recent employment [1] and continue with all past employment.

Employer 1

Employer

Address

Phone

Job Title

Supervisor

Reason for Leaving

Dates Employed From

Hourly Rate/Salary Start

End

May we contact employer?
Yes	No

Describe you job duties

Employer 2

Employer

Address

Phone

Job Title

Supervisor

Reason for Leaving

Dates Employed From

Hourly Rate/Salary Start

End

May we contact employer?
Yes	No

Describe you job duties

Employer 3

Employer

Address

Phone

Job Title

Supervisor

Reason for Leaving

Dates Employed From

Hourly Rate/Salary Start

End

May we contact employer?
Yes	No

Describe you job duties

Employer 4

Employer

Address

Phone

Job Title

Supervisor

Reason for Leaving

Dates Employed From

Hourly Rate/Salary Start

End

May we contact employer?
Yes	No

Describe you job duties

Attendance and Punctuality Information

Consistent attendance and punctuality are essential requirements of every job with this company. Is there anything which would interfere with your regular attendance and punctuality if you are offered a job with this company?

Yes	No
If yes, please explain

Section 4 Education

	Name & Address of School	Major Subject	Years Completed	Graduate	Degree
High School				Yes No
Technical College				Yes No
College				Yes No
Graduate School				Yes No
Other (Specify)				Yes No
Describe any specialized training, apprenticeship, skills, extra-curricular activities, or additional information for consideration.

Section 5 Personal or Business References

Please identify one reference of a supervisor from a previous employer.

Reference 1

First Name

Last Name

Phone

Title / Relationship

Address

City

State

Zip

Reference 2

First Name

Last Name

Phone

Title / Relationship

Address

City

State

Zip

Reference 3

First Name

Last Name

Phone

Title / Relationship

Address

City

State

Zip

Reference 4

First Name

Last Name

Phone

Title / Relationship

Address

City

State

Zip

Section 6 Voluntary Invitation to Identify for Affirmative Action Purposes

Our company is an equal opportunity employer and does not discriminate in hiring or employment on the basis of race, color, religion, sex, national origin, age, disability, or other basis prohibited by federal, state, or local law. No question on this form is intended to secure information to be used for such discrimination. The company is required by federal regulations to report information as requested below. Your contribution of this information is completely voluntary and in no way affects the decision regarding your employment opportunity. The information you provide is strictly confidential and will be maintained separate from you application form.

Personal

First Name	Last Name	Social Security Number or CWID (optional)
Gender Male Female	Job Title

Ethnic Origin

Please read the definitions below and mark the appropriate ethnic origin option
	Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
	White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
	Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa.
	Asian (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
	Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other pacific Islands.
	American Indian or Alaska Native (Not Hispanic or Latino) - A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.
	Two or More Races (Not Hispanic or Latino) - All persons who identify with more than one of the above five races.
	I do not wish to provide this information to The Peerless Chain Company.

Section 7 Disability or Veteran Status

	I am neither a veteran nor a person with a disability
	I am a person with a disability.("Disability" is a physical or mental impairment that substantially limits one or more major life activities.)

Veteran Status

Please check all that describe your veteran status:
	I am a Veteran	Latest date of discharge or release:
	I am a "Special Disabled Veteran" (A veteran who is entitled to compensation by the Veterans Administration for a disability rated at 30% or more, or 10 or 20% percent under Section 3106 of Title 38 USC covering serious employment handicap, or a person who was discharged or released from active duty because of service-connected disability.)
	I am a "Veteran of the Vietnam era" (A veteran who served on active duty for more than 180 days, any part of which occurred between August 5, 1964 and May 7, 1975, and was honorably discharged or released sooner because of a service-related disability.)
	I am a "Recently Separated Veteran" (A veteran for whom less than one year has passes since the date of discharge or release from active duty.)
	I am an "Other Protected Veteran" - (A person who served on active duty during a war or in a campaign or expedition for which a campaign badge has been authorized under laws administrated by the Department of Defense.)

Applicant Statement

I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE AND COMPLETE, I UNDERSTAND THAT THE FALSIFICATION, MISREPRESENTATION OR OMISSION OF FACT ON THIS APPLICATION (OR ANY OTHER ACCOMPANYING OR REQUIRED DOCUMENTS) WILL BE CAUSE FOR DENIAL OF EMPLOYMENT OR IMMEDIATE TERMINATION OF EMPLOYMENT, REGARDLESS OF WHEN OR H0W DISCOVERED.

Questions regarding this statement should be directed to any employment interviewer before signing. The application will be given every consideration, but its receipt does not imply that the applicant will be employed.

It is the policy of the company to afford equal opportunity to all employees and applicants for employment without regard to age, race, religion, color, sex, national origin, marital status, expunged juvenile records, or pregnancy, and to afford equal opportunities to disabled veterans, veterans of the Vietnam era, and individuals with a disability, any and other characteristic protected by Federal, State or Local law.

I authorize the investigation of all statements and information contained in this application. I release from all liability anyone supplying such information and I also release the employer from all liability that might result from making an investigation.

If hired, I agree to abide by all of the company rules and regulation, and understand that, if employed, my employment may be terminated with or without cause, and with or without notice, at any time, at the option of either the company or me, I further understand that no representation, whether oral or written by any representative or agent of the Company, at any time, can constitute a contract of employment. I understand that the Company and all Plan Administrators shall have the maximum discretion permitted by law to administer, interpret, modify, discontinue, enhance or otherwise change all policies, procedures, benefits or other terms or conditions of employment. No representative or agent of the company, has the authority to enter into any agreement for employment for any specified period of time or to make any change in any policy, procedure, benefit or other term or condition of employment other than in a document signed by the President or Executive Vice President, or to make any agreement contrary to the foregoing.

DO NOT SUBMIT UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.

I acknowledge that I have read and understand the above statements and hereby grant permission to confirm the information supplied on this application by me.*

Your application will be maintained in our files for a period of two (2) years. If after two years you still wish to be considered for employment, you are encouraged to fill out another application.

If your address or phone number changes during this time, please contact us indicating the correction.

Online Application for Employment

PEERLESS INDUSTRIAL GROUP

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