APPLICATION FOR EMPLOYMENT

A pre employment physical and drug urinalysis at the company's expense is a condition of employment,
and I agree to such test.

In compliance with Federal and State Equal Employment Opportunity Laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, or the presence of a non-job related medical condition or handicap.

* Required
   A. PERSONAL INFORMATION
 First Name* 
 		 Last Name* 
 Phone with area code* 
 Position
 Are any relatives employed by this company?
 		 Name
 Driver's License Number
 (Driver's license may be required later.) 		 Issuing State
  		  Expiration
  
 Social Security Number:
 (Your Social Security will be required later. ) 		 Referred by
 Current
 Address
 		  Street
 		 City
 		 State
 		 ZIP
 # of Years
 Have you ever been convicted of a felony
  If yes, explain below
 Are you prevented from lawfully becoming employed in this country because of visa or immigration status
 
   B. EDUCATION
Highest Level
Name
Location
Years
Attended
Subjects
Studied
High
School
Jr. College
or College
or University
Business or
Trade School
Other
Languages
Spoken
 
   C. EMPLOYMENT HISTORY - List present or most recent employer first
 Company Name
  Telephone
 Street Address
  Date Employed
 City, ST and ZIP Code
  Rate of Pay
 		  Start
 Contact Person or Supervisor
  Pay Period
  End
 Primary Responsibilities
 Reason for leaving or seeking leave
 Positions
 Company Name
  Telephone
 Street Address
  Date Employed
 City, ST and ZIP Code
  Rate of Pay
 		  Start
 Contact Person or Supervisor
  Pay Period
  End
 Primary Responsibilities
 Reason for leaving or seeking leave
 Positions
 Company Name
  Telephone
 Street Address
  Date Employed
 City, ST and ZIP Code
  Rate of Pay
 		  Start
 Contact Person or Supervisor
  Pay Period
  End
 Primary Responsibilities
 Reason for leaving or seeking leave
 Positions
 
   D. DRIVING SKILLS AND EXPERIENCE
List all violations of motor vehicle laws or ordinances (other than violations involving only parking) of which you were convicted or forfeited bond or collateral during the 3 years preceding the date of this application.
Date Violation Location
Have you ever had a license, permit or privlege to operate a motor vehcile denied, revoked or suspended?
  If yes, please give facts and circumstances in detail
Date Violation Explanation
 
 
I understand and voluntarily agree that:

1. The information that I have provided on this application is true and complete to the best of my knowledge. Any misrepresentation or omission of any fact in my application, resume, or any other materials, or during any interviews, can be justification for refusal of employment, or if employed, termination from Tiller Corporation’s employ.

2. Any offer of employment I may receive from Tiller Corporation is contingent upon my successful completion of the Company’s total pre-employment screening process, including the Company’s receiving references that it considers satisfactory, and my satisfactory completion of any post-job offer pre-employment physical examination, if required.

3. I understand that as a condition of employment, I may be required to undergo and successfully pass a screening for alcohol and/or drugs. I also understand and agree that, if employed, I may be required to submit to an alcohol or drug screening at any time at the discretion of Tiller Corporation.

4. I authorize and request that all of my present and former employers and those individuals I have listed as personal references furnish information about my employment record, including a statement of the reason for the termination of my employment, work performance, abilities, and other qualities pertinent to my qualifications for employment, hereby releasing them from any and all liability for damages arising from furnishing the requested information.

5. In consideration of my employment, I agree to comply with the policies, rules, regulations, and procedures of the Company and understand that my employment and compensation can be terminated with or without cause or notice, at any time at the option of either the Company or me. I further understand that no manager or representative of the Company, other than the President, has authority to enter into any agreement with me for employment for any specified period of time or to make any agreement different from or contrary to any Company policy. I further understand that any such agreement, if made, shall not be enforceable unless it is in writing and signed by me and the President of Tiller Corporation.


 E-mail address
 (You will be e-mailed a notice that your application
 has been received.)
 By checking the box below I signify I have read the statements above and at the top of this application.
 
I agree*