Date

YYYY

Name

First Name

Last Name

Present Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

What position are you applying for?

How did you hear about our company and this job opening?

Have you ever worked for RPM-PSI before?

Yes

If yes, when?

Why are you interested in working at RPM-PSI?

What are you looking for in a company?

If hired, would you have a reliable means of transportation to and from work?

Yes

Are you at least 18 years old? (If under 18, hire is subject to verification that you are of minimum legal age.)

Yes

Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation?

Yes

If no, describe the functions that cannot be performed

(Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Hire may be subject to passing a medical examination, and to skill and agility tests.)

We may refuse to hire relatives of present employees if doing so could result in actual or potential problems in supervision, security, safety, or morale, or if doing so could create conflicts of interest.

EDUCATION, TRAINING, AND EXPERIENCE

High School

Name & Address

Number of Years Completed

Did you graduate?

Yes

Degree or Diploma

––––––––––––––––––––––––––––––

College/University

Name & Address

Number of Years Completed

Did you graduate?

Yes

Degree or Diploma

––––––––––––––––––––––––––––––

Vocational/Business

Name & Address

Number of Years Completed

Did you graduate?

Yes

Degree or Diploma

EMPLOYMENT HISTORY

List below all present and past employment starting with your most recent employer (last five years is sufficient). You must complete this section even if attaching a resume.

Employer #1

Name of Employer

Type of Business

Your Supervisor's Name

Company Address

Company Phone

(###)

###

####

Dates of Employment

Is this your current employer?

Yes

Your Position and Duties

Reason for Leaving

May we contact this employer for a reference?

Yes

––––––––––––––––––––––––––––––

Employer #2

Name of Employer

Type of Business

Your Supervisor's Name

Company Address

Company Phone

(###)

###

####

Dates of Employment

Is this your current employer?

Yes

Your Position and Duties

Reason for Leaving

May we contact this employer for a reference?

Yes

REFERENCES

List below three persons not related to you who have knowledge of your work performance within the last three years.

Reference #1

First Name

Last Name

Phone

(###)

###

####

Address

Occupation

Number of Years Acquainted

––––––––––––––––––––––––––––––

Reference #2

First Name

Last Name

Phone

(###)

###

####

Address

Occupation

Number of Years Acquainted

––––––––––––––––––––––––––––––

Reference #3

First Name

Last Name

Phone

(###)

###

####

Address

Occupation

Number of Years Acquainted

PLEASE READ CAREFULLY, INITIAL EACH PARAGRAPH, & SIGN BELOW

I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

I hereby authorize RPM-PSI to thoroughly investigate my references, work record, education and other matters related to my suitability for employment (excluding criminal background information) unless otherwise specified above. I further authorize the references I have listed to disclose tot he company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the Company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.

I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and the Company. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or the Company, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the Company's designated representative.

In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire.

The Company will consider qualified applicants, including those with criminal histories, in a manner consistent with state and local "Fair Chance" laws.

E-Signature

Date

YYYY

Your application has been submitted. Thank you for your interest in RPM-PSI.

Employment Application

Please complete the form below