/ HARVEY INDUSTRIES DIE CASTING, LLC.
EMPLOYMENT APPLICATION
HARVEY INDUSTRIES DIE CASTING, LLC IS AN EQUAL OPPORTUNITY EMPLOYER and fully subscribes to the principles of Equal Employment Opportunity. HARVEY INDUSTRIES DIE CASTING, LLC has adopted an Affirmative Action Program to ensure that all applicants and employees are considered for hire, promotion and job status, without regard to race, color, religion, sex, national origin, age, veteran status or disability. HARVEY INDUSTRIES DIE CASTING, LLC ALSO CONDUCTS POST-OFFER SUBSTANCE ABUSE TESTING.
PLEASE PRINT INFORMATION REQUESTED IN INK. / DATE
LAST NAME / FIRST / MIDDLE / TELEPHONE
STREET ADDRESS / CITY / STATE / ZIP CODE
HAVE YOU EVER BEEN CONVICTED OF A FELONY? / SOCIAL SECURITY NUMBER
NO / YES / EXPLAIN
POSITION OR TYPE WORK YOU SEEK / OFFICE / IF FACTORY, CIRCLE
FACTORY / SHIFT PREFERENCE / 1 / 2 / 3
OFFICE OR PLANT MACHINES YOU OPERATE AND ANY OTHER SPECIAL SKILLS / RATE OF PAY EXPECTED
PER WEEK / PER HOUR
HAVE YOU APPLIED TO HARVEY INDUSTRIES BEFORE? / HAVE YOU WORKED FOR A HARVEY INDUSTIES CO. BEFORE?
NO / YES / WHEN? / NO / YES / WHEN?
HOW WERE YOU REFERRED TO HARVEY INDUSTRIES? / REFERRAL NAME
ADVERTISEMENT / EMPLOYMENT AGENCY / EMPLOYEE / OTHER
TYPE OF SCHOOL / NAME OF SCHOOL / CITY / ST / CIRCLE LAST YEAR COMPLETED / DID YOU GRADUATE? / DATE OF DEGREE
DEGREE/MAJOR
ELEMENTARY / 5 / 6 / 7 / 8
HIGH SCHOOL / 9 / 10 / 11 / 12
COLLEGE / 1 / 2 / 3 / 4
BUSINESS OR
TRADE / 1 / 2 / 3 / 4
OTHER / 1 / 2 / 3 / 4
GRADE AVERAGE / RANK IN CLASS
IN HIGH SCHOOL / IN COLLEGE / IN HIGH SCHOOL / IN COLLEGE
EXTRACURRICULAR ACTIVITIES
IN HIGH SCHOOL
EXTRACURRICULAR ACTIVITIES
IN COLLEGE
BRANCH OF U.S. MILITARY SERVICE ONLY / ACTIVE DUTY / STARTING RANK / FINAL RANK
FROM / TO
MILITARY SPECIALTY / TYPE OF DISCHARGE
HONORABLE, GENERAL OR UNDESIRABLE / DISHONORABLE OR BAD CONDUCT, EXPLAIN
HOBBIES OR RECREATIONAL PURSUITS

HR: Z:\HRHarvey\Forms\HR001 - Employment Application Package.doc09/25/0

EMPLOYMENT HISTORY: LIST ALL EMPLOYMENT STARTING WITH PRESENT OR MOST RECENT EMPLOYER. BE SURE TO SIGN THE APPLICATION.

1. JOB TITLE
2. DEPARTMENT / REASON FOR
DATES / EMPLOYER’S NAME & ADDRESS / 3. NAME OF SUPERVISOR / DESCRIBE JOB DUTIES / WAGES / LEAVING
FROM / 1. / STARTING
MO. / YR. / 2. / $ / PER
TO / 3. / FINAL
MO. / YR. / $ / PER
FROM / 1. / STARTING
MO. / YR. / 2. / $ / PER
TO / 3. / FINAL
MO. / YR. / $ / PER
FROM / 1. / STARTING
MO. / YR. / 2. / $ / PER
TO / 3. / FINAL
MO. / YR. / $ / PER
FROM / 1. / STARTING
MO. / YR. / 2. / $ / PER
TO / 3. / FINAL
MO. / YR. / $ / PER
FROM / 1. / STARTING
MO. / YR. / 2. / $ / PER
TO / 3. / FINAL
MO. / YR. / $ / PER

EMPLOYMENT AGREEMENT

I hereby authorize the Company to contact my former employers concerning my qualifications for the position for which I have applied. I agree to release from all liability all employers or persons supplying such information.
I understand that I may be required to take a physical examination (after accepting employment) for the purpose of determining pre-existing conditions for insurance purposes, or job related disability.
In consideration of wages or salaries paid to me, I agree to disclose promptly all discoveries, inventions or copyrightable material relating to the Company business. I will assign all my interest in such inventions or copyrightable material and will do other acts as necessary to assist the Company to obtain patents or copyrights on them in any and all countries. These provisions for inventions and copyrights will be binding upon my heirs and may be transferred by the Company to its successor. I will not reveal or use any secret confidential information concerning the Company’s business including the manner of pricing its products, discoveries and methods of manufacturing. Any unpatented inventions conceived prior to the date of this agreement are hereby declared on the attached list. I also understand my falsification or withholding of requested information on this employment application may cause my dismissal.
Applicant’s Signature: / Date:

HR: Z:\HRHarvey\Forms\HR001 - Employment Application Package.doc12/23/03

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Applicant Acknowledgement of
Substance Abuse Policy

In an effort to provide its employees with a working environment that is free of the problems associated with the use and abuse of drugs, controlled substances and alcohol, HARVEY INDUSTRIES DIE CASTING, LLC, Inc. has implemented a Substance Abuse Policy. All applicants for employment who are made an offer of employment are required to submit to a drug and/or alcohol screening test as part of the application process. Failure to submit to or successfully complete the drug/alcohol test will result in your being rejected for consideration for employment with the Company for a period of not less than 12 months. In the event that you pass the pre-employment screening test, and are hired, you will be required to comply with the terms and conditions of the Substance Abuse Policy. Your failure to comply with any of these terms and conditions will result in your being subject to disciplinary action, up to and including termination.
I, ______(print name), acknowledge that I have been notified of the Company’s Substance Abuse Policy, and understand that, if hired, I must abide by that Policy as a condition of continued employment.

Applicant's Signature
Date

HR002 – Applicant Substance Abuse12/23/03

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Background Investigation Authorization

Authorization and General Release
I, ______hereby authorize HARVEY INDUSTRIES DIE CASTING, LLC, Inc. and/or its agents to make an independent investigation of my background, references, character, past employment, education, criminal or police records, medical and/or Workman’s Compensation claims, educational institutions, criminal records, motor vehicle driving records including those maintained by both public and private organizations and all public records for the purpose of confirming the information contained on my application and/or obtaining other information which may be material to my qualifications for employment. Pursuant to the Fair Credit Reporting Act, I understand a credit report may be obtained about me for employment purposes.
I release HARVEY INDUSTRIES DIE CASTING, LLC, Inc. and/or its agents and any person or entity, which provides information pursuant to this authorization, from any and all liabilities, claims or law-suits in regards to the information obtained from any and all of the above referenced sources used.

I authorize that a telephonic facsimile (FAX) or photocopy of this authorization be accepted with the same authority as the original.

The following is my true and complete legal name and all information is true and correct to the best of my knowledge:

Full Name (Printed) / Maiden Name or other Names Used
Present Street Address / Former Street Address
PresentCity, State, Zip / FormerCity, State, Zip
Social Security Number / Date of Birth
A date of birth is needed to process your background investigation. It is intended solely for that purpose and will not be considered in making a hiring decision.
Driver’s License No: / State of Issue
Applicant's Signature / Company Representative
Human Resources
Date / Job Title

HR02912/23/03