HARTUNG
HARTUNG GLASS INDUSTRIES

NOTE: PLEASE ASK IF YOU NEED ASSISTANCE COMPLETING THIS APPLICATION.

LAST NAME FIRST NAME MIDDLE INITIAL

STREET ADDRESS CITY STATE ZIP CODE

HOME/MESSAGE PHONE ( ) ______WORK ( ) ______

For what position are you applying? What date are you available to start work?

Shift(s) Available: Days Evenings Nights Would you prefer to work: Full time Part time Temporary

Will visa or immigration status prevent lawful employment? Yes No Proof of right to work in the U.S. will be required if hired.

Are you 18 years or older? Yes No If no, employment is subject to minimum legal age requirements.

Have you been convicted of a crime or released from prison within the past ten years? (A conviction may not necessarily disqualify you from employment.) Yes No

If yes, please indicate the date and nature of the offense

What are your starting wage or monthly salary expectations?

Have you ever previously applied to or been employed by this company? If yes, when?

How did you learn about this opening?

EDUCATION / GRADUATE
Name and Location of School / Years Completed / Yes / No / Degrees Received
High School
College
Trade
Business, or
Graduate School

Were you known by any other name at any job or school listed on this application? Yes No If yes, what name?

At which job or school were you known by this name:

Our production positions require that you be able to lift 50 or more pounds regularly throughout an eight (8) hour work day. Is that a problem?

Yes

No

Are you able to work overtime? Yes No

EQUAL OPPORTUNITY EMPLOYER

EMPLOYMENT RECORD (INCOMPLETE APPLICATIONS CANNOT BE ACCEPTED)

Please start with most recent employer, include military service. If currently employed, may we contact your employer? Yes No

Employer Type of business Telephone ( )

Address City State Zip Code

Job Title Supervisor Telephone ( )

Dates Employed: From To Reason for leaving Wage

Duties

Employer Type of business Telephone ( )

Address City State Zip Code

Job Title Supervisor Telephone ( )

Dates Employed: From To Reason for leaving Wage

Duties

Employer Type of business Telephone ( )

Address City State Zip Code

Job Title Supervisor Telephone ( )

Dates Employed: From To Reason for leaving Wage

Duties

Employer Type of business Telephone ( )

Address City State Zip Code

Job Title Supervisor Telephone ( )

Dates Employed: From To Reason for leaving Wage

Duties

APPLICANT'S STATEMENT

I certify that answers given herein are true and complete to the best of my knowledge.

I authorize the Company to investigate all statements contained in this application and to request information about me from previous employers and educational institutions. I expressly authorize my previous employers to provide information and opinions concerning my work and work habits. Further, I release all parties (the Company) and persons connected with any requests for information from all claims, liabilities, and damages for whatever reason, arising out of furnishing any information that may be sought in arriving at an employment decision.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in dismissal. I also understand that I am required to abide by all current and subsequently issued rules and regulations of the Company and that employment is for no definite period and may be terminated, at any time, with or without notice, by either party.

Signature of Applicant Date

05/99

DRUG AND ALCOHOL POLICY

Hartung Glass Industries is committed to producing products of the highest quality and providing a safe and productive work environment for employees. Consistent with this commitment is our policy to maintain a drug and alcohol-free workplace. To help and maintain this environment, we have implemented a pre-employment drug-screening program. Under this program, all job applicants and temporary employees may be required to submit to a urinalysis exam conducted by an independent laboratory of our choice. A negative result will be a condition of employment. Any applicant or new hire that tests positive will be ineligible to work and may not reapply for a position within six months.

By signing below, I hereby consent to testing for the presence of unauthorized drugs, and I authorize the release of the test results to Hartung Glass Industries. I also authorize Hartung Glass or the laboratory to obtain any necessary medical information from my physician, treating hospital, or other treating health or substance abuse professional. I hereby release Hartung Glass Industries from any and all claims, demands, or liabilities that may arise in connection with the administration of the test or use of the test results.

I fully understand that any offer of employment or temporary placement is contingent on my successful passing the screening process, and that any misrepresentation or attempt to tamper with that sample submitted may be grounds for immediate withdrawal of an offer of employment, or disciplinary action, including dismissal, if I am employed or temporarily placed.

Applicant’s Name (PLEASE PRINT)______

Applicant’s Signature: ______

Date: ______