Application for Employment

Please Read Carefully BEFORE submitting.

By pressing the 'Submit' button you certify;

•  that the statements within are true
• you have read, understand and agree to all provisions within this application
• understand that misrepresentation of this application or any provisions herein may subject you to disqualification or immediate dismissal
• understand that employment is at will; and specifically agree that employment can be terminated, with or without cause or notice, at the option of yourself or the company
• If hired, you agree to provide proof of citizenship or legal right to work in the U.S. on the first day of employment

By pressing the 'Submit' button you authorize Middlesex Glass Company Inc.;

1.  to use the information contained in this form or in my personal file to contact my previous employers about my qualifications for the position you are applying
2. to use the information contained in this form or in my personal file to answer job related inquiries from possible future employers
3. to use the information contained in this form or in my personal file to contact schools for pertinent information

Name

Address

Number, Street, City, State, Zip code

Phone Number

Position Applying For

Are you are willing to work Overtime:

Yes No

Have you ever applied to Middlesex Glass Company before? If Yes, when did you apply?

Referal Source

Please tell us how you found Middlesex Glass Company. Did you recieve a referal from a friend or relative? Find us on the internet?

Starting Rate Desired

When can you start?

Work History - Most Recent

Please provide you work history in chronilogical order starting with your most recent experiance and working backwards. You may include any verifiable work performed on a volunteer bases,internships, or military service. Be certain to include: Company Name Company Location Dates of Employment Position Held Duties Performed Reason for Leaving Manager Contact Information (If you have held no previous positions please enter Not Applicable)

Work History A

Be certain to include: Company Name Company Location Dates of Employment Position Held Duties Performed Reason for Leaving Manager Contact Information (If you have held no previous positions please enter Not Applicable)

Work History B

Be certain to include: Company Name Company Location Dates of Employment Position Held Duties Performed Reason for Leaving Manager Contact Information (If you have held no previous positions please enter Not Applicable)

Work History C

Be certain to include: Company Name Company Location Dates of Employment Position Held Duties Performed Reason for Leaving Manager Contact Information (If you have held no previous positions please enter Not Applicable)

Work History D

Be certain to include: Company Name Company Location Dates of Employment Position Held Duties Performed Reason for Leaving Manager Contact Information (If you have held no previous positions please enter Not Applicable)

Education

Please provide the names and locations of the high school, college and/or technical school you have attended. Please indicate your course of study, if you have graduated, what years you've completed, and any degrees/certification you've obtained. Please indicate if you have graduated from these institutions.

Additional Skills

Please provide any additional skills or training you feel pertains to the position you are applying for.

Are you able to perform all functions of the position applied for with reasonable accomodations?

Yes No

Have you ever been convicted of a felony?

Yes No

Have you ever initiated an act of violence in the work place?

Yes No

If yes, please explain so individual circumstances may be considered.

Please provide a brief explaination of what you may have been convicted for, and/or the circumstances surrounding the act of violence.

Have you been convicted of any misdemeanor within the last 5 years?

Yes No

If yes, please explain so individual circumstances may be considered.

Please include dates and locations of offenses. EXCLUDES: First convictions for drunkeness. Simple assault Speeding Minor Traffic Violations Affray Disturbing the Peace.

References: Please provide the name of a person; not related, you have known the past 3 years.

Please provide the Name, Address, Phone number of the person whom you use as a reference, please indicate if the reference is personal or professional.

References: Please provide the name of a person; not related, you have known the past 3 years.

Please provide the Name, Address, Phone number of the person whom you use as a reference, please indicate if the reference is personal or professional.