Application for employment ARKANSAS POLY & PRINTING, INC. An Equal Opportunity Employer Step 1 of 3 33% Date of Application* Date Format: MM slash DD slash YYYY Name* First Last SSN*Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Alternate PhoneRELATIONS working for Arkansas Poly, LLCName First Last RelationshipTYPE OF WORK preferred*Date Available* Date Format: MM slash DD slash YYYY Are you willing to work:Over 40 hours per week* Yes No Twelve Hour Shifts* Yes No Irregular Shifts* Yes No Nights* Yes No Saturdays or Sundays* Yes No EDUCATIONplease check highest grade completedHigh School 9 10 11 12 College 13 14 15 16 DegreeGraduate School*any other schools, special training or achievementsCITIZENSHIPIf you are not a U.S. Citizen, does your visa or immigrations status permit lawful employment? Yes No N/A If employed, can proof of citizenship, visa or alien registration number be provided? Yes No N/A CRIMINAL OFFENSESHave you been convicted of a felony within the last seven years or have you been imprisoned for the conviction of a crime in the past 7 years?* Yes No Date of Conviction Date Format: MM slash DD slash YYYY CircumstancesTHE EXISTENCE OF A RECORD OF CONVICTION FOR CRIMINAL OFFENSES IS NOT CONSIDERED AN AUTOMATIC BAR TO EMPLOYMENT WITH ARKANSAS POLY & PRINTING, LLC. EMPLOYMENT EXPERIENCE:(list most recent 1st, etc.)Job TitleEmployerSupervisorPhone NumberDatesPay RateType of Work PerformedReason for LeavingJob TitleEmployerSupervisorPhone NumberDatesPay RateType of Work PerformedReason for LeavingJob TitleEmployerSupervisorPhone NumberDatesPay RateType of Work PerformedReason for LeavingCERTIFICATION AND ACKNOWLEDGEMENTConsent*I authorize Arkansas Poly & Printing, LLC to obtain information about me from my previous employers, schools, and other sources offered. I authorize previous employers, schools that I have attended, and all other reference sources to disclose to Arkansas Poly & Printing, LLC such information about me as Arkansas Poly & Printing, LLC may request. In addition, I hereby release the company, my former employers, and all other persons from any and all claims, demands, or liabilities arising out of, or in any way related to, such disclosure. I verify that the statements I have made in this application are true and complete. I understand that if I am hired, any false or incomplete statements in this application will be grounds for immediate discharge. I acknowledge that if hired, I will be an at will employee. I will be subject to dismissal or discipline without notice or cause, at the discretion of the employer. I understand that no representative of the company, other than the President, V.P. or General Manager has the ability to change the terms of an at will employment and that any such change can occur only in a written employment contract. The use of, possession of, or being under the influence of Medical Marijuana at work or during work hours is prohibited. I have read and agree to the statements above.*Name* First Last Date* Date Format: MM slash DD slash YYYY EMPLOYMENT REFERENCE CONSENT AND RELEASEApplicant Name* First Last SSN*Consent* I HEREBY GIVE CONSENT TO ANY AND ALL PRIOR EMPLOPYERS OF MINE, OR MY CURRENT EMPLOYER, TO PROVIDE THE INFORMATION BELOW WITH REGARD TO Arkansas Poly & Printing, LLC.*This consent is valid for a period of six (6) months from the date indicated. A copy shall serve as an original.Signature*Date* Date Format: MM slash DD slash YYYY Instructions to Current/Former EmployerThe individual named above has applied for employment with our company. Please respond candidly to the requests for information listed below and return your written responses via either facsimile or email. This Consent and Release is intended to comply with Arkansas Act 1474 or 1999, an Act to provide current and former business employers with protection for providing job information about current or former employees to prospective employers. PLEASE RETURN THE INFORMATION TO: By fax: 479-471-8947 Or by email to Melissa Driscoll mdriscoll@arkpoly.com or Carrie Johnson cjohnson@arkpoly.comDate & duration of employmentCurrent or last rate of pay/wage historyCurrent or last job description and dutiesThe details of the applicant’s last written performance evaluation prepared prior to the date the applicant signed this consent (see date above)Attendance history (Excluding any qualifying leave under FMLA)Results of drug &/or alcohol tests administered within the last yearDetails of any threats of violence, harassing acts, or threatening behavior related in any way to the workplace or directed at another employeeWas his/her separation from employment voluntary or involuntary?What was the reason for the applicant’s separation from employment?Is the applicant eligible for rehire? Yes No Name and title of representative providing informationDate Date Format: MM slash DD slash YYYY Phone
