DIEMAKER JOURNEYMAN

Date

Personal Information

Last Name

First Name

Middle

Address

Suite etc.

City

State

Zip

Telephone

Are you 18 years old or older ? Yes No

Referred by

Have you ever been convicted of a crime ?

Conviction of a crime, is not necessarily a bar to employment.

Convicted Yes No

If so, when ?

Where ?

Nature of Offense

Employment Desired

Position

Date you can start

Salary desired

Are you employed now ? Yes No

If so, may we contact your current employer ? Yes No

Have you applied to this company or it's affiliates before ? Yes No

Where ?

When ?

Are you willing to work nights ? Yes No

Education

Grammer

Name & Location

Years attended

Course

Did You Graduate ? Yes No

High School

Name & Location

Years attended

Course

Did You Graduate ? Yes No

College

Name & Location

Years attended

Course

Did You Graduate ? Yes No

Other

Name & Location

Years attended

Course

Did You Graduate ? Yes No

Military

U.S. Military or Naval Service

Rank at Discharge

Type of Discharge

References

Give the names of persons not related to you, whom you have known at least one year

Name

Address

Business

Years

Name

Address

Business

Years

Former and Current Employers

List the last four employers, beginning with the current or most recent

1: From [Date] To [Date]

Name & Address of Employer

Salary

Position

State all reasons for leaving or termination

Name/Phone of immediate supervisor

2: From [Date] To [Date]

Name & Address of Employer

Salary

Position

State all reasons for leaving or termination

Name/Phone of immediate supervisor

3: From [Date] To [Date]

Name & Address of Employer

Salary

Position

State all reasons for leaving or termination

Name/Phone of immediate supervisor

4: From [Date] To [Date]

Name & Address of Employer

Salary

Position

State all reasons for leaving or termination

Name/Phone of immediate supervisor

Please upload your resume here. Resumes must be in either Adobe Acrobat (.pdf) or Microsoft Werd (.docx or .doc) formats.

Attach a Resume

I hereby waive written notice from my employer and from any of my former employers regarding the disclosure of disciplinary reports, letters of reprimand, or other notices of disciplinary action contained in my personnel records. this waiver is made pursuant to Section 6 of Act No. 397 of the Public Acts of 1978.

I certify the information in this application is correct to the best of my knowledge and understand that any falsification, misrepresentation or omission of information is grounds for a rejection of this application or dismissal from employment f I am hired.

If employed, I understand tha if I am, or become, handicapped in need of accommodations for employment, I must notify the Managing Director in writing within 182 days after the need is known.

I authorize the references and previous employers listed above to give you any and all information concerning my previous employment and any pertinent information they have, personal or otherwise, and release all parties from any liability for any damages which may result from furnishing same to you.

I hereby attest that I am not currently using any illegal drugs and that if employed, I agree I will not use any illegal drugs at any time while in such employ.

In consideration of my employment, I agree to conform to the rules and regulations of Autodie LLC and its affiliates. I agree that my employment and compensation can be terminated with or without cause and with or without notice at any time at the option of the Company or myself. I understand that no officer or representative of the company other than the Managing Director of the Company, has any authority to enter into any agreement of employment for any specified period of time or to make any agreement contrary to the foregoing, and that any such agreement must be in writing.

I have read and agree to the terms of each and all of the above six (6) individual statements:

Signature