MOELLER MFG. CO., INC. APPLICATION FOR EMPLOYMENT

An Equal Opportunity Employer

Fax: 248-960-8858 Email:

PERSONAL INFORMATION
Last Name First Name Middle Initial / Social Security Number:
Street Address City/State Zip Code / Phone Number:
Email / Are you 18 or older? / Are you a veteran?
DESIRED EMPLOYMENT
Position Desired: / Wage/Salary Desired: / Date you can start:
Ever applied here before? / If yes, when? / If worked here before, reason for leaving:
Ever worked here before? / If yes, when?
If worked here before, name of last supervisor:
HOW DID YOU HEAR ABOUT MOELLER?
Sign out by road? / Vehicle sign? / Craigslist?
Tear-off sign in store? / Television? / Michigan Works?
Moeller employee? / Newspaper? / Career Builder?
I-96 Billboard? / Other (Please specify)
EDUCATION
Name and location of grammar school: / Years attended? / Graduate? / Subjects studied?
Name and location of high school attended: / Years attended? / Graduate? / Subjects studied?
Name and location of college: / Years attended? / Graduate? / Subjects studied?
Name and location of technical / correspondence school: / Years attended? / Graduate? / Subjects studied?
Are you presently enrolled in school? / If yes, give name & address of school and expected degree date:
GENERAL
Subjects of special study or research work?
Special training?
Special skills?
Have you been convicted of a felony
Within the last 5 years? / If yes, explain (will not necessarily exclude you from consideration)
FORMER EMPLOYERS
List below last three former employers, starting with most recent
Name of Employer: / Job Title:
Duties:
Address: / Dates of Employment:
From: To:
City, State, Zip Code / Hourly pay or salary:
Starting pay: Ending pay:
Description of work:
Supervisor:
Telephone: / Reason for Leaving:
Name of Employer: / Job Title:
Duties:
Address: / Dates of Employment:
From: To:
City, State, Zip Code / Hourly pay or salary:
Starting pay: Ending pay:
Description of work:
Supervisor:
Telephone: / Reason for Leaving:
Name of Employer: / Job Title:
Duties:
Address: / Dates of Employment:
From: To:
City, State, Zip Code / Hourly pay or salary:
Starting pay: Ending pay:
Description of work:
Supervisor:
Telephone: / Reason for Leaving:
AUTHORIZATION
“I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.
I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise and release Moeller from all liability that may result from utilization of such information.
I also understand and agree that no representative of Moeller has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized Moeller representative.”
Signature: / Date:
REFERENCES
Please provide three persons you are not related to, whom you have known for at least one year
No / Name / Address / Business / Years known
1
2
3
FOR COMPANY USE ONLY
Interview by: / Date:
Comments:
Hired Date: / For Department: / For Position:
Salary / Wages: / Will Report:
Employment Manager Approval / Date
Department Manager Approval / Date
General Manager Approval / Date