Myers Industries, Inc

Application for Employment

Applicants will receive consideration without discrimination because of race, color, religion, sex, national origin, age, disability, sexual orientation, marital, veteran or citizenship status, or other status protected by federal, state or local law.

Print
Name Last First Middle Initial / Home Phone
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Street
Address / Cell Phone
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CityStateZip / E-Mail Address
Have You Applied to this or any other Myers Industries Company Before?
No Yes, if Yes, When, Where, and for What Job?
Were You Ever Employed by this No
Or any Myers Industries Company? Yes -- If Yes, Where? When? From: /To: /
Are You Related To Anyone No
At This Company? Yes -- Their Name & Relationship:
Are You Seeking: Temporary
Full Time Part Time / Date You Can Start:
/ / Salary Desired:
Job(s) You Are Applying For: / Shifts You Can Work: 12 hr 8 hr
1st 2nd 3rd Any
Will You Travel?
Yes No / Will You Relocate?
Yes No / List Any Travel Or Relocation Restrictions:
If Resume is Not Attached or Submitted, List Computer Hardware, Software, And Applications With Which You Have Experience:
If Resume is Not Attached or Submitted, List Office Machines You Can Operate: / Words Per Minute: / Keystrokes Per Hour:
If Resume is Not Attached or Submitted, List Shop And Factory Machines With Which You Have Experience:
If Resume is Not Attached or Submitted, List Skilled Trades In Which You Have Experience:
Type Of School / School Name / Graduated? / Grade Point Average / Number Of Years Attended
And Degree Or Field Of Study
Yes / No / GED
High School / -
-
Business, Trade, Tech Or Voc. / -
-
College Or University / -
-
-
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Other Training Or Military
If You Plan Further
Education Explain:
Have You Ever Been Convicted Of A Felony? No
(Conviction May Not Necessarily Disqualify You) Yes / If Yes, list year, city and state, and nature of the offense:

Start with your present or last job, and list all jobs including temporary and military.

Job Title / Dates Employed:
From / To /
Employer / Starting Pay / Current Or Final Pay
Address / Summarize The Type Of Work Performed/Job Responsibilities
Or Attach Your Resume
City, State Zip
,
Telephone
() -
Current Or Final Supervisor’s Name & Title
May We Contact? Yes No / Why Did You Leave Or Why Do You Wish To Leave?
Job Title / Dates Employed:
From / To /
Employer / Starting Pay / Current Or Final Pay
Address / Summarize The Type Of Work Performed/Job Responsibilities
Or Attach Your Resume
City, State Zip
,
Telephone
() -
Current Or Final Supervisor’s Name & Title
May We Contact? Yes No / Why Did You Leave Or Why Do You Wish To Leave?
Job Title / Dates Employed:
From / To /
Employer / Starting Pay / Current Or Final Pay
Address / Summarize The Type Of Work Performed/Job Responsibilities
Or Attach Your Resume
City, State Zip
,
Telephone
() -
Current Or Final Supervisor’s Name & Title
May We Contact? Yes No / Why Did You Leave Or Why Do You Wish To Leave?
Job Title / Dates Employed:
From / To /
Employer / Starting Pay / Current Or Final Pay
Address / Summarize The Type Of Work Performed/Job Responsibilities
Or Attach Your Resume
City, State Zip
,
Telephone
() -
Current Or Final Supervisor’s Name & Title
May We Contact? Yes No / Why Did You Leave Or Why Do You Wish To Leave?

Job history continued

List Your References Or Attach A Separate Sheet. Work References Are Preferred.

Name / How Do You Know This Person
Telephone Number
() - / Company If Work Reference
Position If Work Reference
Name / How Do You Know This Person
Telephone Number
() - / Company If Work Reference
Position If Work Reference
Name / How Do You Know This Person
Telephone Number
() - / Company If Work Reference
Position If Work Reference
Name / How Do You Know This Person
Telephone Number
() - / Company If Work Reference
Position If Work Reference

Buckhorn Inc.

Application for Employment

Release and Acknowledgement

Read Carefully Before Signing

I certify that the information set forth in this application is true, correct, and complete. I understand that if employed, falsified statements on this application or omission of pertinent information including that given at the time of my physical examination, if required, shall be considered sufficient cause for immediate dismissal.

I authorize all schools, former employers, references, and others who have information about me to provide such information to Buckhorn and its affiliated companies. I release all parties includingBuckhorn and its affiliated companies from any liabilities for any damages that may result from providing such information.

I understand that any offer of employment or continued employment may be conditional upon: 1) my passing a physical examination and drug test; 2) other job-related tests; 3) providing proof of my valid driver’s license, insurability and safe driving record if applicable; and 4) providing proof of my eligibility to work in the U.S., and 5) meeting all other criteria required by the job.

I agree that any claims or lawsuits relating to my application to or service with Buckhorn or any of its affiliated companies must be filed no more than six (6) months after the date of the employment action that is the subject of the claim or lawsuit. I waive any statute of limitations to the contrary.

If employed:

I will use the Company’s Open Door Communications Process prior to taking any action or making any claim outside of the company.
I agree to read and comply with all the rules and policies of the company. If I do not understand something, I will ask my supervisor for clarification.
I further agree that my employment is at will, and that my employment and compensation can be terminated, with or without cause and with or without notice, at any time, at the option of either the Company or myself.
I understand that no employee other than an officer of the company has any authority to enter into an agreement for any specified period of time, or to make any agreement contrary to current company practices and policies, and that any such agreement must be in writing.
I further acknowledge that the Company can modify, change, or rescind in whole or in part at any time and without liability to anyone the policies, practices, and or benefits contained in the Employee Handbook, documents, memoranda, or otherwise.
At any time after an offer of or during my employment, I agree to submit, where allowed by law, to a medical examination to determine my abilities to perform the essential functions of the job and to tests for illegal drugs and alcohol. I authorize the examining physician to disclose to the Company or its representative the results of such examination and tests. I understand and agree that my refusal to cooperate and submit to such exams and tests will constitute sufficient grounds for my immediate discharge. I also understand that if test results indicate the presence of illegal substances or alcohol, I shall be immediately discharged.

This application will be considered active for twelve months from the date signed. If you are hired, it becomes part of your official employment record. Also, federal law requires that you provide proof of citizenship or authorization to work in the U.S. within 72 hours of your hire date. (Or proof within 72 hours that you have applied for proper documentation to satisfy this requirement.) If you cannot provide this proof, the offer of employment may be rescinded and your employment may be terminated.

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Signature Date

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Print Name Social Security Number

Applicant Survey

Various agencies of the United States Government require employers to maintain information on applicants pertaining to factors such as race, sex, and type of position for which an individual applies. The information requested on this sheet is for compliance with certain record keeping requirements. The Company believes all persons are entitled to equal employment opportunities and does not discriminate against its employees or applicants for employment because of race, color, sex, religion, national origin, disability, veteran status, age, marital status or any other protected group status.

Part I of this survey is required. Part II is optional, but it is very useful data for us. Any information volunteered will be kept confidential and will not be used to make hiring decisions.

Part I Required

Name: Date: / /

Zip Code: Last 4 digits of Phone Number:

Job opening for which you are applying:

(For Office Use Only: Job Group: Job #: EEO #: )

How did you learn about this job opening:

A Advertisement (identify publication, name of website, etc):

B Employee Referral (identify employee):

C Other (identify agency name, job fair, college, etc):

Part II Optional

Sex:

Male Female

Race/ Ethnicity:
1Hispanic / Latino / 5 Native Hawaiian or Other Pacific Islander (not Hispanic)
2 White (and not Hispanic/Latino) / 6 Native American or Alaska Native (not Hispanic)
3 Black / African American (not Hispanic/Latino) / 7 Two or More Races (not Hispanic/Latino)
4 Asian (not Hispanic/Latino) / 9Prefer not to disclose

Please separate this form from the application and give to the receptionist. Thank you!

Application for Employment 03/21/2013

Applicant Authorization and Release to Obtain Information

Back of Applicant Survey.

Myers Industries, Inc. and its Companies (The "Company") requires, as a condition of employment, and/or continued employment, that all applicants consent to and authorize a verification of the information submitted on their application or resume. Please read this statement carefully.

I, the undersigned applicant, do hereby certify that the information provided by me for the purpose of employment is true and complete to the best of my knowledge. I understand that if I am employed, any false statements will be cause for dismissal.

This release and authorization acknowledges that this Company may now, or at any time while I am employed, conduct a verification of my education, employment history, credit history, and/or motor vehicle records. In addition this company may contact personal references, require that I provide a specimen to be tested for the presence of drugs or alcohol, and receive any criminal history record information pertaining to me which may be in the files of any Federal, State or Local criminal justice agency in any state, and/or other information as deemed necessary. Also, if an offer of employment has been made, I authorize review of my worker’s compensation claim history.

I authorize Asurint and any of its agents and/or employees to disclose verbally and in writing the results of this verification process to the designated authorized representatives of this Company. The results will be used to determine employment eligibility under this Company's employment policies.

I have read and understand this release and consent, and I authorize the background verification. I authorize persons, schools, current and former employers, and other organizations and Agencies to provide Asurint with all information that may be requested, and I hereby release all of the persons and agencies providing such information from any and all claims and damages connected with their release of any requested information. I agree that any copy of this document is as valid as the original.

I do hereby agree to forever release and discharge this Company, its agent, Asurint, and their associates to the full extent permitted by law from any claims, damages, losses, liabilities, costs and expenses, or any other charge or complaint filed with any agency arising from the retrieving and reporting of information. According to the Federal Fair Credit Reporting Act, I am entitled to know if employment was denied based on information obtained by my prospective employer, and to receive, upon written request, a disclosure of the public record information and of the nature and scope of the investigative report. If I am a current resident of Minnesota, California or Oklahoma only and would like a copy of the investigative report, I will check here:

I agree that a copy of this authorization has the same effect as an original.

Full Name (print clearly)

SignatureDate: / /

*****THE INFORMATION SUPPLIED BELOW WILL ONLY BE USED TO REQUEST & VERIFY RECORDS*****

Current address:

Maiden name / Prior names used at work:

**Current employees please provide the following information. If you are an Applicant, Stop Here. The information below will be completed by or requested of you when a conditional job offer is being made**

Social Security Number: - - Date of birth: / /

Driver’s License Number: Or State ID Number: State: Expiration date: / /

Back of Authorization for Background Check

10/10/12Asurint Phone/Fax 800-906-1674