MAINTEX, INC. EMPLOYMENT APPLICATION

13300 E. Nelson Avenue, City of Industry, California 91746

Telephone: (626) 961-1988 | Fax: (626) 961-3129

Maintex supports equal employment opportunity for all applicants and employees and therefore does not unlawfully discriminate in the hiring or employment practices on the basis of race, sex, color, age, religion, national origin, sexual orientation, marital or veteran status, medical condition, disability or any other legally protected status.

Date of Application:

PLEASE PRINT OR TYPE

PERSONAL INFORMATION
Last Name First Name Middle / Home Phone / Message Phone
Address Apt. # P.O. Box / Business Phone
City State Zip
If hired, can you provide verification of your legal right to work in the United States:
¨ Yes ¨ No / Other names known by: / Are you 18 years old or older?
¨ Yes ¨ No
Position Desired / Type of Employment Desired
¨ Full-time ¨ Part-Time ¨ Temporary / Salary Desired
$ ______¨ Per month ¨ Per Hour
Are you able to perform the essential job functions of the job for which you are applying?
¨ Yes ¨ No If “NO”, describe how you would perform the job with or without reasonable accommodation:
Have you ever applied at Maintex? ¨ Yes ¨ No
If “YES”, when did you apply? / Do you have any friends or relatives working for Maintex? ¨ Yes ¨ No
If “YES”, please provide name(s) and work location:
Have you ever been convicted of a felony? ¨ Yes ¨ No If “YES”, list offense, date and disposition of the case:
Note: You do not need to report the following: (1) any conviction for which the record has been judicially expunged, sealed or eradicated, such as certain juvenile offense records; (2) any arrest for which a pretrial diversion program has been successfully completed; or (3) convictions for certain marijuana violations that are more than two (2) years old, per California Labor Code section 432.8

EDUCATION AND TRAINING

Please include any training relative to the position you are applying for, including military:
Colleges, Vocational or Technical Schools, Training Centers / Major Subject / Units / Type of Degree
or Certificate / Date
LICENSES AND CERTIFICATES REQUIRED FOR, OR RELATED TO, THIS POSITION
Description / Issued by / ID # / Expiration Date

PERTINENT SPECIAL SKILLS

Please list experience with machines, office equipment, languages, or other special skills pertinent to the position for which you are applying.

ADDITIONAL INFORMATION

Do you possess a valid driver’s license (if job required)? ¨ Yes ¨ No State: Driver’s License # ______ Class: ______
Automobile Make:______Model:______Year______
If a driver’s license is required by the job, have you received any tickets in the last three years for moving violations? ¨ Yes ¨ No
Date:_____ ______Violation: ______
Date: ___________Violation: ______
Do you give Maintex, Inc. permission to order a Motor Vehicle Report? ¨ Yes ¨ No
Do you give Maintex, Inc. permission to perform a criminal background check? ¨ Yes ¨ No
WORK EXPERIENCE
Beginning with your Present or most recent employer, describe all Work Experience including Military, Volunteer and Intern Experience.
(Attach additional sheets if necessary)
Name of Present or Most Recent Employer / Address
Starting Date / Leaving Date / Reason for Leaving
Month/Year / Month/Year / Salary $ ____ per _____
¨ Full Time ¨ Part Time _____ hrs/wk
¨ Volunteer ¨ Intern _____ hrs/wk
Job Title (Present or Most Recent) / Name of Supervisor/Title / Phone #
Job Duties:
May we contact this employer? ¨ Yes ¨ No
Name of Employer / Address
Starting Date / Leaving Date / Reason for Leaving
Month/Year / Month/Year / Salary $ _____ per _____
¨ Full Time ¨ Part Time _____ hrs/wk
¨ Volunteer ¨ Intern _____ hrs/wk
Job Title (Present or Most Recent) / Name of Supervisor/Title / Phone #
Job Duties:
May we contact this employer? ¨ Yes ¨ No
Name of Employer / Address
Starting Date / Leaving Date / Reason for Leaving
Month/Year / Month/Year / Salary $ _____ per _____
¨ Full Time ¨ Part Time _____ hrs/wk
¨ Volunteer ¨ Intern _____ hrs/wk
Job Title (Present or Most Recent) / Name of Supervisor/Title / Phone #
Job Duties:
May we contact this employer? ¨ Yes ¨ No
PLEASE READ CAREFULLY, INITIAL EACH PARAGRAPH, AND SIGN BELOW.
Initial / In consideration of employment, I agree to comply with the policies and standards of Maintex, Inc. I understand and agree that my employment is at-will, and may be terminated at any time, with or without notice and with or without cause, by either Maintex or by me. I also understand that, except for the at-will status of my employment, any other term of my employment may be changed at any time by the Company, without notice, and without the need for cause or further consideration. Other than this paragraph, I understand and agree that no other contract regarding my employment, written or oral, will be effective, unless it is signed by the ownership, or an authorized representative, of Maintex, Inc. Finally, I agree that this paragraph is intended as the final and complete statement of the parties on the topics in this paragraph, and that any other statement or representation is merged into and superceded by this paragraph.
Initial / I understand that as a condition of hire and continuing employment, I may be required to submit to a criminal background check as well as enroll in the DMV Pull Program, depending on the job that I am being considered for. I understand that if Maintex receives a notification of a criminal record, I may be disqualified for further consideration for employment, and, at the Company’s sole discretion unless required by law, such records received may be justification for my dismissal from employment, if discovered at a later date. I understand that I am entitled to receive a copy of said document the Company received.
Initial / I understand that as a condition of employment I may be required to take a pre-placement physical examination which includes but is not limited to a drug test. I also understand that at any time during my employment, I may be required to take a physical examination which may include but is not limited to an alcohol and drug test if management reasonably suspects a condition exists that will prevent me from performing my job in a manner that does not endanger my own health of the safety and health of others. In the event that I have a disability which will affect my ability to take the test, I will so inform the Company so that a reasonable accommodation can be made. The Company reserves the right to require medical documentation concerning the need for documentation.
Initial / I authorize any person, school, current employer (except as expressly noted), past employer(s) and organizations named in this application form (and accompanying resume or other documentation, if any) to provide the Company with relevant information and opinion, personal or otherwise, that may be useful in making a hiring decision. I release all parties from all liability for any damage that may result from furnishing information and opinion to you.
Initial / I understand that all offers of employment are conditioned upon my providing satisfactory documentary proof of my identity and legal right to work in the United States.
Initial / I hereby acknowledge that I have read the above statements and understand them. I certify that I, the undersigned applicant, have personally completed this application. I declare under penalty of perjury that the facts contained in the application (or any resume or other documents submitted) are true and complete to the best of my knowledge. I understand that any misrepresentations or omissions will disqualify me from further consideration for employment, and will be justification for my dismissal from employment, it discovered at a later date.
Applicant Signature: / Date:
Signature of Applicant’s Parent or Legal Guardian (If the applicant is under 18 years) / Date:

MAINTEX, INC.

VOLUNTARY AFFIRMATIVE ACTION INFORMATION

In an effort to comply with requirements regarding government recordkeeping, reporting and other legal obligations, we ask that you complete the information below. Your cooperation is appreciated. Please note that this form is not used in hiring decisions and will be kept separate from your employment application.

Applicant Name : ______

Position Applied For: _ Sex: ¨ Female ¨ Male

Date of Application: Date of Birth: _____ / ____ / _____

Month Day Year

RACIAL AND ETHNIC IDENTIFICATION
¨ WHITE/CAUCASIAN
(not of Hispanic or Latino origin) / A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
¨  BLACK OR AFRICAN AMERICAN
(not of Hispanic or Latino origin) / A person having origins in any of the black racial groups of Africa.
¨ HISPANIC OR LATINO / A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture of origin, regardless of race.
o ASIAN
(not of Hispanic or Latino origin) / A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.
o NATIVE HAWAIIAN OR OTHER
PACIFC ISLANDER
(not of Hispanic or Latino origin) / A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
o AMERICAN INDIAN OR
ALASKAN NATIVE
(not of Hispanic or Latino origin) / A person having origins in any of the original peoples of North and South America (including Central America) who maintain tribal affiliation or community attachment.
¨ TWO OR MORE RACES
(not of Hispanic or Latino origin) / A person who identifies with more than one of the above 5 races.

EQUAL EMPLOYMENT OPPORTUNITY: We are an Equal Opportunity/Affirmative Action Employer. We are dedicated to a policy of nondiscrimination in employment on the basis of race, color, religion, sex, national origin, age, or mental and/or physical disability.

IMMIGRATION LAW: In accordance with the Immigration Reform and Control Act of 1986 (IRCA), all newly hired employees will be required to complete and sign an Employment Eligibility Verification Form and present documentation verifying identity and employment eligibility within 3 business days following their start date.

MAINTEX, INC.

US VETERAN STATUS INFORMATION

Applicant Name ______

Position Applying For: ______

Date: ______

PLEASE CHECK ANY OF THE FOLLOWING THAT IS APPLICABLE:

SPECIAL NOTICE TO VIETNAM ERA VETERANS, DISABLED VETERANS AND INDIVIDUALS WITH PHYSICAL OR MENTAL HANDICAPS OR DISABILITIES:

Government contractors/vendors subject to the Vietnam Era Veterans Readjustment Act of 1974 and the Rehabilitation Act of 1973 are required to take affirmative action to employ and advance qualified disabled veterans of the Vietnam Era and qualified handicapped individuals.

£  Special Disabled Veteran: A (i) veteran of the US military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Department of Veterans’ Affairs for a disability (A) rated at 30 percent or more, or (B) rated at 10 or 20 percent in the case of a veteran who has been determined under Section 38 U.S.C. 3106 to have a serious employment handicap or (ii) a person who was discharged or released from active duty because of a service-connected disability.

£  Veteran of the Vietnam era: Means a person who (i) served on active duty in the U.S. military, ground, naval or air service for a period of more than 180 days, and who was discharged or released there from with other than a dishonorable discharge, if any part of such active duty was performed: (A) in the Republic of Vietnam between February 28, 1961 and May 7, 1975; or (B) between August 5, 1964 and May 7, 1975, in all other cases, or (ii) was discharged or released from active duty in the U.S. military, ground, naval or air service for a service-connected disability if any part of such active duty was performed (A) in the Republic of Vietnam between February 28, 1961 and May 7, 1975; or(B) between August 5, 1964 and May 7, 1975 in any other location.

£  Newly Separated Veterans: Means any veteran who served active duty in the U.S. military, ground, naval or air service during the one-year period beginning on the date of such veteran’s discharge or release from active duty.

£  Other Protected Veterans: Means veterans who served on active duty in the U.S. military, ground, naval or air service during a war or a campaign or expedition for which a campaign badge has been authorized. Employees with Internet access may access information required to make this determination by logging on at http://www.opm.gov/veterans.html/vgmedal2.html.

£ Not applicable.