Mercer Controls, Inc.--Application for Employment

Please complete the form below:

Date
First Name	*		Last Name	*
Phone Number	*		Email Address	*
Address	*
City	*		State / Province	*	- - Choose One - - - - US States - - AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY - - Canada Provinces - - AB BC MB NB NL NT NS NU ON PE QC SK YT
Zip / Postal
Marital Status	*	Single Married Divorced Widowed	Gender	*	Male Female
No. of Dependents	*		Are you at least 18 years of Age?	*	YES NO
Are you allowed to work in the US?	*	YES NO
Date Available for Work	*		Job Status	*	Full-Time Part-time Summer Temporary
Are your willing to stay out of town if the job requires?	*	YES NO	Have you ever been convicted of a felony?	*	YES NO
If YES, Explain:	*
Document available to Establish Identity	*	Driver's License or ID Card issued by a state ID Card issued by federal, state or local government School ID Card with a photograph Voter's Registration Card U.S. Military Card or Draft Card Military Dependent's ID Card U.S. Coast Guard Merchant Mariner Card Native American Tribal Document Driver's license issued by Canadian government U.S. Passport Permanent Resident Card or Alien Registration Receipt Card Unexpired Foreign Passport with temporary I-551 stamp Unexpired Employment Authorization with photograph Unexpired Foreign Passport with Arrival-Departure Record	Document available to Establish Employment Eligibility	*	U.S. Social Security Card issued by SSA Certification of Birth Abroad issued by the Dept of State Original or Certified Copy of Birth Certificate issued by State Native American Tribal Document U.S. Citizens ID Card ID Card for use of Resident Citizens in the US Unexpired Employment Authorization Document with photograph U.S. Passport Permanent Resident Card or Alien Registration Receipt Card Unexpired Foreign Passport with Temporary I-551 stamp Unexpired Foreign Passport with and Unexpired Arrival-Departure Record
Highest School Grade Finished			Did you Graduate?
Name of High School			Location	*
College Attended			College Hours Completed
Major			Special Licenses or Certificates Held
Did you serve in the Military?		YES NO
Branch			Rank
Are you in the reserves?		YES NO	National Guard?		YES NO
Employment Record: Begin with Current or Most Recent Employer and Work Background
1. Company Name	*
Company Address	*		Company Phone No.
Start Date	*		End Date	*
Job Title	*		Pay Rate	*
Job Duties	*		Supervisor's Name
Reason for Leaving	*
2. Company Name	*
Company Address	*		Company Phone No.
Start Date	*		End Date	*
Job Title	*		Pay Rate	*
Job Duties	*		Supervisor's Name
Reason for Leaving	*
3. Company Name	*
Company Address	*		Company Phone No.
Start Date	*		End Date	*
Job Title	*		Pay Rate	*
Job Duties	*		Supervisor's Name
Reason for Leaving	*
ALL POSITIONS HAVE THE FOLLOWING MINIMUM QUALIFICATIONS:
1. THE ABILITY TO UNDERSTAND SPOKEN ENGLISH WELL ENOUGH TO RESPOND TO OUR INSTRUCTIONS AS WELL AS TO HAZARD WARNINGS GIVEN BY OUR EMPLOYEES.			2. THE ABILITY TO READ AND UNDERSTAND WRITTEN ENGLISH.
3. THE ABILITY TO WORK OUTDOORS THE FULL WORKDAY OF EIGHT TO TWELVE HOURS, WINTER OR SUMMER, UNLESS THE WEATHER CONDITIONS ARE SUCH THAT THE TECHNICIAN IN CHARGE DETERMINES THAT DANGER TO PERSONNEL IS APPARENT.			4. THE ABILITY TO LIFT 70 POUNDS OCCASIONALLY AND TO ASSIST IN LIFTING HEAVIER LOADS.
I am applying for the position of			The salary I expect per hour $	*
I am capable of discharging the responsibilities of this job to the satisfaction of Mercer Controls, Inc. I will abide by all procedural and safety regulations of Mercer Controls, Inc.
Abide by all procedural and safety regulations	*	YES NO
I understand that my undivided attention to the job is necessary while in the workplace, for the safety of myself as well as of the co-workers. If any situation or condition exists now or occurs later which impairs my ability to perform the job for which I was hired, I will notify a supervisor immediately. I understand that Mercer Controls, Inc. alone has the right to determine if I can perform the job for which I was hired. I am willing to submit to randomly scheduled Drug Test as a condition of employment.
Random Drug Testing	*	YES NO
All statements made on this form are true and correct to the best of my knowledge. Any misstatement or omission will constitute grounds for unfavorable consideration or dismissal. Mercer Controls, Inc. is authorized to make any and all inquiry as to the correctness of the statements on this application.
All statements are true	*	YES NO