RIC Application for Employment

Rochester Industrial Control

Application for Employment

RIC is an Equal Opportunity Employer

RIC (the Company) is an equal opportunity employer, which makes employment decisions without regard to race, color, gender, religion, national origin, age, disability, marital status, veteran status, or any other characteristic protected under federal, state or local law. The Company also reasonably accommodates individuals with disabilities and bona fide religious beliefs. It complies with, and fully supports the Americans with Disabilities Act.

The information requested on this form and its supplement is needed to evaluate your application for employment with this Company.

Note: All questions on the form must be answered, incomplete applications will not be processed.

Personal Data
Date:
Name (last, first, middle):
Street Address:
City, Zip, State:
*Social Security Number:
Phone Number:
E-mail Address:
Are you over the age of 18?	Yes No
Have you previously been employed by RIC?	Yes No
Have you previously submitted an employment application?	Yes No
When?
For What position?

Employment Data
Positions applying for:
Type of position:
Date available to work:
Minimum salary requirement $:
Have you signed any non-compete agreement with any other employer that would restrict you from working at RIC?	Yes No

Work History
Start with your most recent position. If you have worked for any company as a temporary or contract employee, please specify that clearly under the appropriate employer, making sure to include the agency's name and telephone number. Give accurate summaries of your duties, concentrating on major aspects of the position including number of personnel supervised, financial responsibilities and major accomplishments. Periods of unemployment should also be noted. Leave no gaps in time sequence.
From:
Company name:
City, State:
Telephone:
Starting job title:
Present (or last) job title:
Summarize job responsibilities and duties:
Immediate supervisor's name:
Supervisor's job title:
Reason for leaving:
Rate of pay:
May we contact this employer now?	Yes No
If not, when?

From:
Company name:
City, State:
Telephone:
Starting job title:
Present (or last) job title:
Summarize job responsibilities and duties:
Immediate supervisor's name:
Supervisor's job title:
Reason for leaving:
Rate of pay:
May we contact this employer now?	Yes No
If not, when?

From:
Company name:
City, State:
Telephone:
Starting job title:
Present (or last) job title:
Summarize job responsibilities and duties:
Immediate supervisor's name:
Supervisor's job title:
Reason for leaving:
Rate of pay:
May we contact this employer now?	Yes No
If not, when?

Did you ever work for any employers under a different name?	Yes No
If yes, please show which employer and under what name.
Have you ever received any disciplinary action within the last 12 months of active employment?	Yes No
If yes at your option, explain the details fully.

Education
High School name:
City/State located:
Dates attended:
Highest grade completed:
Did you graduate?	Yes No
Diploma/Degree acquired:

College name:
City/State located:
Dates attended:
Highest grade completed:
Did you graduate?	Yes No
Diploma/Degree acquired:

Vocational/technical school name:
City/State located:
Dates attended:
Highest grade completed:
Did you graduate?	Yes No
Diploma/Degree acquired:

Other:
City/State located:
Dates attended:
Highest grade completed:
Did you graduate?	Yes No
Diploma/Degree acquired:

If you did not graduate, why did you leave school or college?
Did you ever attend school under a different name?	Yes No
If yes, what schools and what name?
List educational awards, honors or unique activities:

Additional Skills
Personal computer hardware skills:
Personal computer software programs:
Do you know sign language?	Yes No
What foreign languages do you speak or write?
What type of licenses do you have?
What certifications do you have?
What patents do you have?
List areas of special experience:

US Military Experience
Have you served in the Armed Forces?	Yes No
What military branch?
Date entered:
Date discharged:

Other Critical Data
Have you ever been convicted of, pleaded guilty or no contest to, entered a pre-trial diversion or similar program concerning any criminal offense (misdemeanor or felony) including but not limited to crimes of dishonesty, or breach of trust?	Yes No

Include any guilty pleads or convictions pursuant to a pre-trial diversion program. Do not include minor traffic violations other than DWI/DUI/DUE. Do not include any convictions or pleas as a youthful offender or juvenile. Do not include any criminal proceedings which have been terminated in your favor. Responses concerning pre-trial diversions or unresolved charges or arrests should not be provided in states which restrict such inquiries.

Have you been charged with or arrested for any criminal offense described above for which you are awaiting disposition, dismissal, termination, further court proceedings or final resolution?	Yes No

Include any pending criminal case which has been postponed pursuant to a pretrial diversion or similar program.

If you answered "YES" to either question, please note that where consistent with applicable law, a conviction or unresolved criminal charge or arrest will not result in an automatic disqualification from employment. Where appropriate factors such as date(s), nature, job-relatedness and seriousness of the offense will be considered.

I understand and agree that my employment is subject to satisfactorily passing a drug screen and the successful completion of reference checks.	Yes No

I agree that RIC may make inquiries of courts and law enforcement agencies for possible pending charges and convictions including those involving the abuses, diversion and/or illicit distribution and/or sale of controlled drugs. I hereby authorize these courts and law enforcement agencies to divulge any and all information related to pending charges and convictions.	Yes No

I understand that if I accept an offer if employment, past employers/educational institutions and/or the military may be contacted for references, and I hereby authorize such inquiries, agree that this application may be used in such inquiries and agree that I will sign any necessary release authorizing such entities to provide RIC with my complete employment, education and/or military background, including information and opinions regarding my character, ability, performance, attendance, punctuality, conduct and reasons for termination.	Yes No

I understand and agree that, consistent with applicable law, I am obligated to immediately inform the Company and update any information including any pending criminal convictions, or guilty please, no contest to, and entry into pretrial diversion or similar program concerning prosecution for a criminal offense, and that failure to do so many result in disqualification of my application or termination of my employment whenever discovered.	Yes No

I understand that nothing contained in this employment application is intended to lead to or create an employment contract between RIC and me. I further understand and agree that the employment relationship that may result from my application will be an employment-at-will and either RIC or I may terminate my employment at any time for any reasons or for no reason and with or without notice. I understand that no employee (including any officer) of RIC has the authority to alter the employment-at-will relationship, orally or in writing. I further agree that I am subject to and will follow the Company's policies and procedures. Including, but not limited to, and procedures are guidelines and shall not be considered to impose any contractual obligations on the Company. I further understand that the Company may change its policies and procedures without notice to or consent by its employees.	Yes No

I certify that the statements made in this application are true and correct to the best of my knowledge and I understand and agree that any misstatement, false information or omission of fact, or failure to timely provide verification of information provided on the application will result in disqualification of my application or termination of my employment whenever discovered. I have been assured that the Company will treat the results of such inquiries in the strictest of confidence.	Yes No

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