APPLICATION FOR EMPLOYMENT

Mitsubishi Fuso Truck of America, Inc. is an equal opportunity employer,

complying with all applicable federal and state laws.

Please Print.

PERSONAL INFORMATION

NAME

Last First Middle

PRESENT ADDRESS

Street City Zip

PHONE NO.______SOCIAL SECURITY NUMBER______

DRIVERS LICENSE NO.______STATE______

ARE YOU AT LEAST 18 YEARS OLD? YES___NO___IF HIRED, CAN YOU PROVIDE PROOF OF YOUR ELIGIBILITY TO WORK IN THE UNITED STATES? YES___NO___

EDUCATION

NAME/ YEARS DEGREE/

TYPE LOCATION COURSE COMPLETED DIPLOMA

Elementary &

Jr. High

High School

College

Technical or

Other

EMPLOYMENT RECORD List below your last three employers starting with the last one first.

DATE NAME, ADDRESS PAY REASON FOR

Started/Left PHONE # OF EMPLOYER RATE POSITION LEAVING

1.

2.


EMPLOYMENT RECORD (Cont’d)

DATE NAME & ADDRESS PAY REASON FOR

Started/Left of EMPLOYER RATE POSITION LEAVING

3.

TYPE OF WORK DESIRED______SALARY/WAGE DESIRED______

IF CURRENTLY EMPLOYED, MAY WE CONTACT YOUR PRESENT EMPLOYER? YES____NO____

DATE YOU CAN START______

HOW WERE YOU REFERRED TO OUR ORGANIZATION______

CAN YOU PERFORM THE FUNCTIONS OF THIS JOB, WITH OR WITHOUT REASONABLE ACCOMMODATION?

YES___NO___

DO YOU HAVE ANY RELATIVES WHO ARE EMPLOYED BY THIS ORGANIZATION? YES___NO___

If yes, please specify.______

PLEASE LIST ANY ADDITIONAL INFORMATION THAT RELATES TO YOUR ABILITY TO PERFORM THE JOB FOR WHICH YOU HAVE APPLIED - SUCH AS LICENSES, PROFESSIONAL MEMBERSHIPS, HOBBIES, ETC.

REFERENCES List below at least three persons not related to you whom you have known at least one year.

TELEPHONE YEARS

NAME ADDRESS NUMBER OCCUPATION KNOWN

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APPLICANT’S STATEMENT

I understand the employer follows an “ employment at will” policy, in that I or the employer may terminate my employment at any time, or for any reason consistent with applicable state or federal law; this “employment at will” policy cannot be changed verbally or in writing, unless the change is specifically authorized in writing by the Executive Committee of this organization. I understand that federal law prohibits the employment of unauthorized aliens; all persons must submit satisfactory proof of employment authorization and identity; failure to submit such proof will result in denial of employment.

I understand this application will be active for a period of 60 days; after that time, if I wish to be considered for employment, I must submit a new application.

I understand that the employer will thoroughly investigate my work and personal history and verify all data given on this application, on related papers, and in interviews. I authorized all individuals, schools and firms named therein, except my current employer if so noted, to provide any information requested about me and I release them from all liability for damage in providing this information.

I UNDERSTAND THAT IF OFFERED EMPLOYMENT, I MAY BE REQUIRED TO UNDERGO A MEDICAL EXAMINATION, INCLUDING DRUG TESTING.

I certify that all the statements herein are true and understand that any falsification or willful omission shall be sufficient cause for dismissal or refusal of employment.

Signature______Date______

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