HARLAN CORPORATION APPLICATION FOR EMPLOYMENT
We consider applicants for all positions without regard to race, color, religion, national origin, handicap, age, sex, or veteran status. If an offer is extended and accepted, the new employee must pass a drug screen prior to start date.

Position(s) Applied For:

Date of Application:

How did you learn about this position or our company? (Check as many as apply)

Newspaper Ad internet Site (Name of site:) Employment Agency Friend Relative Walk-In Harlan Employee
(For the current employee to be considered for the Applicant Referral Bonus, show name here:

Last Name First Name Middle Initial

Street Address Apt. # City State Zip Code

Telephone Number: Email:

Social Security Number:

Please answer the following questions:	YES / NO
Have you ever filed an application with us before? If yes, give date
Have you ever been employed with us before? If yes, give date
May we contact your present employer?
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? Proof of citizenship or immigration status will be required upon employment.
If you are under 18, and it is required, can you furnish a work permit?
Are you available to work Saturdays and Sundays?
Will you work overtime if required?
Are you able to meet the attendance requirements of the position?
Can you travel if a job requires it?
Have you been convicted of a felony within the last 7 years? If yes, please explain: Conviction will not necessarily disqualify an applicant from employment.
Can you provide required proof of your eligibility to work? (i.e. driver’s license, social security card, resident alien card)
Type of work for which you are applying? (Check all that apply) Full Time Part Time Temporary Seasonal employment
When are you available to start work?:

Education

	Name and Address of School	Course of Study	Years Completed	Diploma/ Degree
High School
Junior College, Trade School or Other College
Undergraduate College
Graduate Professional
Other (Specify)

Work Related References List references who know your work experience. 1. Check the one that applies and list company name.
Name:		Supervisor	Co-Worker
Address:		Other, Please Specify:
Phone:	Company Name:

Check the one that applies and list company name.

2.
Name:		Supervisor	Co-Worker
Address:		Other, Please Specify
Phone:	Company Name:

Check the one that applies and list company name.

3.
Name:		Supervisor	Co-Worker
Address:		Other, Please Specify
Phone:	Company Name:

Experience and Skills

Describe experience or skills that would be relevant to this job (include computer expertise and special experience):

Employment Experience
Start with your present or last job and fill out completely. It is not acceptable to complete this form by writing in “See Resume.” Include any job-related U.S. military service assignments and volunteer activities. You may exclude organizations that indicate race, color, religion, gender, national origin, disabilities or other protected status. You may be asked to provide verification of rate of pay and/or job title with your current employer upon employment with Harlan Corporation.
1.
Employer		Date Employed (mm/dd/yy)
		From	To	Work Performed
Address
Telephone Numbers		Hourly Rate/Salary
		Starting	Ending
Job Title	Supervisor
Reason for Leaving
May we contact for a reference?

2.
Employer		Date Employed (mm/dd/yy)
		From	To	Work Performed
Address
Telephone Numbers		Hourly Rate/Salary
		Starting	Ending
Job Title	Supervisor
Reason for Leaving
May we contact for a reference?

3.
Employer		Date Employed (mm/dd/yy)
		From	To	Work Performed
Address
Telephone Numbers		Hourly Rate/Salary
		Starting	Ending
Job Title	Supervisor
Reason for Leaving
May we contact for a reference?

4.
Employer		Date Employed (mm/dd/yy)
		From	To	Work Performed
Address
Telephone Numbers		Hourly Rate/Salary
		Starting	Ending
Job Title	Supervisor
Reason for Leaving
May we contact for a reference?

Describe any specialized training, licenses, registrations, certifications, apprenticeship, skills and extra-curricular activities:

Applicant’s Statement

I certify the answers given herein are true and complete to the best of my knowledge. I authorize investigation of any/all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” employment relationship and may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized company officer of this organization. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of Harlan. I understand that Harlan has the right to modify its’ policies without giving any notice of the change(s).

I understand that Harlan has a “Harassment/Discrimination-Free Workplace” Policy that specifically defines and prohibits all forms of harassment; provides a procedure for confidentially reporting potential policy violations without fear of retaliation; and establishes severe penalties up to and including discharge for policy violations. If hired, I understand that if I believe someone may have violated this policy that I should immediately report the potential violation to any Harlan supervisor or manager and/or contact the Human Resources Director.

Signature of Applicant: (by checking this box you accept and sign this application)

Printed Name:

Date: