EMPLOYMENT APPLICATION

Notice: Celgard, LLC has a drug testing policy and you are subject to testing

Celgard, LLC is an equal opportunity employer. All qualified applicants will be considered without regard to race, color, religion, sex, national origin, age, disability, or status as a disabled or Vietnam-era veteran.

GENERAL INFORMATION

Last Name / First Name / Middle Name / Phone No.
Address / City/State/Zip code / Social Security #
Are you prevented from lawfully becoming employed in the U.S. because of visa or immigration status? ( ) Yes ( ) No / Are you over 18 years of age ( ) Yes ( )No.
If not, please give date of birth
Have you ever been convicted of a crime other than a minor traffic violation? If so, explain: (Note: A conviction will not necessarily disqualify you).

EMPLOYMENT INFORMATION

Position Desires / Date available for work / Other type of work in which you are
interested

SKILLS

Office machines operated (list) / Computer software knowledge

EDUCATION

Name of School / City, State / Major course or
Subject / Years
Completed / Degree
Yes or No
High School
College or University
Graduate study
Other (including military)
Please give names and telephone numbers of three work references

Name

/

Title

/

Phone Number

(Complete the other side also)

PRESENT AND PRIOR EMPLOYMENT

List most recent position first

Company name and address / Phone No. / Type of Business
Present or last position / From (date)
To (date) / Final Salary
Briefly describe your duties
Reason for leaving
Company name and address / Phone No. / Type of Business
Present or last position / From (date)
To (date) / Final Salary
Briefly describe your duties
Reason for leaving
Company name and address / Phone No. / Type of Business
Present or last position / From (date)
To (date) / Final Salary
Briefly describe your duties
Reason for leaving
Some people gain job-related experience in positions other than as an employee. For instance, an accountant may gain experience as the treasurer of a specific group or school organization. Please list and describe on a separate sheet any activities, organizational activities, honors, or other activities and experience or training, which might aid you in performing the jobs (s) for which you have applied. (You may omit activities, honors, or memberships, which tend to identify your race, sex, national origin, handicap; or other personal traits, which you prefer not to disclose).

APPLICANT PLEASE READ BEFORE SIGNING

I certify that the above information is true and complete. I recognize that this application will be effective for thirty (30) days and that any misrepresentation or omission of facts may lead to denial of, or discharge from employment.
I authorize (1) the investigation of all information contained in this application; (2) the containing of my references, employers, and other individuals and institutions to obtain information; (3) any individual, employer, or other organization to provide Celgard LLC with any information and opinion; and (4) Celgard LLC to answer any inquiries regarding my employment, conduct, qualifications, and reason for leaving. In exchange for being considered for employment, I release Celgard LLC, its subsidiaries, owners, employees, representatives, and agents from any liability arising from any actions taken related to Sections (1), (2), (4), and under the Fair Credit Reporting Act. I further release any individual, employer, or other organization from any liability for providing information and opinion pursuant to the above
Section (3).
If employed, I understand that: (1) my employment will be “at-will” and may be terminated by me or Celgard LLC at any time, for any reason, and without notice; (2) regardless of any references to wages as yearly, monthly, or weekly, my employment is not for a definite period of time; (3) Celgard LLC may revise and make exceptions to the policies, practices, handbooks, manuals, rules, and regulations in whole or in part, at any time; (4) unless agreed to in writing by the owners of Celgard LLC, no written or oral statements I receive from Celgard LLC will change my status as an “at-will” employee.
Signature: ______/ Date: ______
ADDENDUM TO EMPLOYMENT APPLICATION (OPTIONAL)
Demographic Information
The following information is for Equal Employment Opportunity/Affirmative Action purposes only. To assist Celgard LLC in its commitment to equal employment opportunity, applicants are asked to provide voluntarily the following information. Celgard LLC is authorized under federal law to retain this information for research and statistical reasons. This information will not be used in an employment decision and refusal to provide this information will not affect an applicant’s employment opportunities. Information requested is to be completed on a voluntary basis. Data will be held confidential and only used in accordance with applicable federal law.
(Please select one)
Male Female I do not wish to identify
(Please select one)
White
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
Asian
American Indian or Alaskan Native
Two or More Races
I do not wish to identify