Application for Employment

Corry Rubber Corporation is an Equal Opportunity Employer. Complete the application below, your answers save automatically as you type, so you can finish in more than one sitting.

Application for Employment

Pre-employment questionnaire · An equal opportunity employer

Corry Rubber Corporation is an equal opportunity employer. We consider all applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, veteran status, disability, or any other legally protected status, and we do not ask you to disclose any of it here.

Personal Information

Today's DateEmail

Name

LastFirstMiddle

Home Address

StreetCityStateZip

Home PhoneAre you 18 years or older?YesNo

Are you a U.S. citizen or an alien authorized to work in the United States?YesNo

Employment Desired

PositionDate You Can StartSalary Desired

Are you employed now?May we contact your present employer?

Ever applied to this company before?When?

Referred by

Education

Level	Name & Location of School	Years Attended	Graduated?	Subjects Studied
Grammar School
High School
College
Trade / Business / Correspondence

General

Subjects of special study or research workSpecial skillsActivities (civic, athletic, etc.)

Exclude organizations whose name indicates the race, creed, sex, age, marital status, color or national origin of its members.

U.S. Military or Naval Service

Present membership in National Guard or ReservesRank

Former Employers List below, starting with the most recent.

Dates (mo / yr)	Name & Address of Employer	Salary	Position	Reason for Leaving
FromTo
FromTo
FromTo
FromTo

References

Give the names of three persons not related to you whom you have known at least one year.

#	Name	Address & Telephone	Business	Years Acquainted
1.
2.
3.

In case of emergency, notify

NameAddressPhone

I certify that the answers given by me to the foregoing questions and statements are true and correct without material omissions of any kind. I authorize the companies, schools, and persons named in this application to provide any information regarding my employment, character and qualifications, and I release them from all liability for providing it. I understand that misleading or incorrect statements may render this application void and, if employed, would be cause for termination. I understand that I may be required to undergo a pre-employment physical examination and/or drug test as a condition of employment, and I agree to comply with all safety rules and all rules and regulations of the company.

DateSignature of Applicant (type your full name)

Step 1 of 3 · Personal & Education

Your answers save automatically as you type, so you can finish in more than one sitting.