PICCOLA MANUFACTURING CO

APPLICATON FOR EMPLOYMENT

We are an equal opportunity employer, dedicated to a policy of nondiscrimination in employment on any basis including race, color, age, sex religion, disability or national origin.

Name*

First Middle Last Suffix

Date*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Date Available*

Last 4 Digits SSN*

Desired Salary*

Position Applied for:*

Are you a citizen of the United States?*

yes

no

If no, are you authorized to work in the U.S.?*

yes

no

Have you ever worked for this company?*

yes

no

If so, when?*

Are you employed now?*

yes

no

If so, may we contact your Employer?*

yes

no

Type of Employment*

First Shift

Second Shift

Third Shift

EDUCATION

High School*

Address*

From*

To*

Did you graduate?*

yes

no

Degree*

College or Trade School

Address

From

To

Did you graduate?

yes

no

Degree

Other

Address

From

To

Did you graduate?

yes

no

Degree

OCCUPATIONAL TRAINING/CERTIFICATIONS

Occupational License, Certificate or Registration

Number

Where Issued

Expiration Date

PREVIOUS EMPLOYMENT (LIST PRESENT OR MOST RECENT POSITIONS FIRST)

Company*

Phone*

Address*

Supervisor*

Job Title*

Starting Salary*

Ending Salary*

Responsibilities*

From*

To*

Reason for leaving*

May we contact your previous supervisor for a reference?*

yes

no

Company

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

May we contact your previous supervisor for a reference?

yes

no

From

To

Reason for leaving

Company

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

From

To

Reason for leaving

May we contact your previous supervisor for a reference?

yes

no

MILITARY SERVICE

Branch

From

To

Rank at discharge

Type of discharge

If other than honorable, explain

DISCLAIMER AND SIGNATURE

Consent*

I agree

I certify that my answers are true and complete to the best of my knowledge.
If this application leads to employment, I understand that false or misleading information in my application or interview
may result in my release.

Date*

VOLUNTARY VETERAN SELF-IDENTIFICATION FORM

Please check the applicable categories:

Special Disabled Veteran

yes

is (i) a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under the laws administered by the Department of Veterans Affairs for disability (A) rated at 30 percent or more, or (B) rated at 10 or20 percent in the case of a veteran who has been determined under Section 30 U.S.C. 3106 to have a serious employment handicap or (ii) a person who was discharged or released from active duty because of a service-connected disability

Veteran of the Vietnam Era

yes

is a person who: (i) served on active duty in the U.S. military, ground, naval or air service for a period of more than 180 days, and who was discharged or released there from with other than a dishonorable discharge, if any part of such active duty was performed: (A) in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or (B) between August 5, 1964, and May 7, 1975, in all cases; or (ii) was discharged or released from active duty in the U.S. military, ground, naval or air service for a service-related disability if any part of such active duty was performed (A) in the Republic of Vietnam between February 28, 1961, and May 7,1975; or (B) between August 5, 1964, and May 7, 1975 in any other location

Other Protected Veteran

yes

is a veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized

Newly Separated Veterans

yes

is any veteran who served on active duty in the U.S. military, ground, naval or air service during the one-year period beginning on the date of such veteran's discharge or release from active duty

Thank you - This information is submitted voluntarily, will be kept confidential, will be exclusively utilized for EEO statistical gathering and compliance purposes.

Voluntary Self-Identification of Disability

Why are you being asked to complete this form?

We are a federal contractor or subcontractor required by law to provide equal employment opportunity to qualified people with disabilities. We are also required to measure our progress toward having at least 7% of our workforce be individuals with disabilities. To do this, we must ask applicants and employees if they have a disability or have ever had a disability. Because a person may become disabled at any time, we ask all of our employees to update their information at least every five years.

Identifying yourself as an individual with a disability is voluntary, and we hope that you will choose to do so. Your answer will be maintained confidentially and not be seen by selecting officials or anyone else involved in making personnel decisions. Completing the form will not negatively impact you in any way, regardless of whether you have self-identified in the past. For more information about this form or the equal employment obligations of federal contractors under Section 503 of the Rehabilitation Act, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp

How do you know if you have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition. Disabilities include, but are not limited to:

Autism

Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, or HIV/AIDS

Blind or low vision

Cancer

Cardiovascular or heart disease

Celiac disease

Cerebral palsy

Deaf or hard of hearing

Depression or anxiety

Blind or low vision

Diabetes

Epilepsy

Gastrointestinal disorders, for example, Crohn's Disease, or irritable bowel syndrome

Intellectual disability

Missing limbs or partially missing limbs

Nervous system condition for example, migraine headaches, Parkinson’s disease, or Multiple sclerosis (MS)

Psychiatric condition, for example, bipolar disorder, schizophrenia, PTSD, or major depression

Please check one of the boxes below:

Check one

Yes, I Have A Disability, Or Have A History/Record Of Having A Disability

No, I Don’t Have A Disability, Or A History/Record Of Having A Disability

I Don’t WishTo Answer

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.

For Employer Use Only

Employers may modify this section of the form as needed for recordkeeping purposes.

Piccola Job application

PICCOLA MANUFACTURING CO

APPLICATON FOR EMPLOYMENT

EDUCATION

OCCUPATIONAL TRAINING/CERTIFICATIONS

PREVIOUS EMPLOYMENT (LIST PRESENT OR MOST RECENT POSITIONS FIRST)

MILITARY SERVICE

DISCLAIMER AND SIGNATURE

PICCOLA MANUFACTURING COMPANY EQUAL EMPLOYMENT OPPORTUNITY AND AFFIRMATIVE ACTION QUESTIONNAIRE

VOLUNTARY VETERAN SELF-IDENTIFICATION FORM

Please check the applicable categories:

Thank you - This information is submitted voluntarily, will be kept confidential, will be exclusively utilized for EEO statistical gathering and compliance purposes.

Voluntary Self-Identification of Disability

Why are you being asked to complete this form?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition. Disabilities include, but are not limited to:

Please check one of the boxes below:

For Employer Use Only