Application

*Job Application*
PERSONAL INFORMATION:					Date:	Nov-18-2008
Name:					Telephone:
Address:					Best time To call:
City:	State:		Zipcode:		Referred by:
Are you 18 years or older?		Yes No
Have you ever been convicted of a felony?		Yes No		Date of conviction:
Are you authorized to work in the United States?			Yes No
EMPLOYMENT DESIRED:
Position desired:					Date you can start:
Are you looking for:Full-Time	Full-Time		Part-time (hrs/week)		Wage/Salary Desired:
Have you ever worked for PETERSEN before?			Yes No		When?
Shifts willing to work?	Dayshift		Swingshift*		Graveyard*
MANUFACTURING SKILLS:					( * shift differential * )
Your skills and years of experience:
Machines you operate:
Certificates you hold:
LEADERSHIP SKILLS:
Improvement task teams you have served on and accomplishments achieved:
Other improvements you have been responsible for:
EDUCATION:
		Course of study				Years Completed
High School:
Trade School:
College:
Other:
EMPLOYMENT RECORD:
Present or most recent employer			Please fill out completely

Employer:					Telephone:
Address / City / State / Zip:
From:	to		Starting wage:		Final wage:
Your position and duties:
Reason for leaving:			Name / title of supervisor:

Employer:					Telephone:
Address / City / State / Zip:
From:	to		Starting wage:		Final wage:
Your position and duties:
Reason for leaving:			Name / title of supervisor:

Employer:					Telephone:
Address / City / State / Zip:
From:	to		Starting wage:		Final wage:
Your position and duties:
Reason for leaving:			Name / title of supervisor:

Employer:					Telephone:
Address / City / State / Zip:
From:	to		Starting wage:		Final wage:
Your position and duties:
Reason for leaving:			Name / title of supervisor:
REFERENCES:
List 3 employment or school references whom Petersen Inc. has permission to contact. All names, relationships, years know, and phone numbers should be complete.
Name:	Phone:		Relationship:		Years known:




Petersen is an equal opportunity employer and offers employment to quaified individuals regardless of their race, colr, religion, sex, national origin, age physical or mental handicap, veteran or disabled veteran status, and conforms to all applicable laws and regulations. It is understood and agreed upon that any misrepresentation by me in this application will result in cancellation of this application and, if employed, my employment may be terminated at any time. Furthermore, I understand that my employment is at-will, which means that just as I am free to resign at any time, the employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the employer has the authority to make any assurances to the contrary. I give the employer the right to investigate all references and to secure additional truthful information about me, if job related. I hereby release from liability the employer and its representatives for seeking such information and all other persons, corporations, or organizations for furnishing such information. I authorize the Company to relaese to any person, firm, entity or organization with which I may seek employment in the future, any truthful information concerning my work experience with the Company. I hereby release and hold the Company harmless from any claim for releasing any truthful information within its knowledge and/or records. I hereby voluntarily consent to a physical examination and/or tests to be conducted by company-designated physicians and/or other appropriate medical personnel. If employment is offered, I speciically volunteer for testing to determine the presence of drugs and/or alcohol in my system. I voluntarily authorize the release of the test results to the management of this company for use in determining my eligibility for employment. I understand that only those applicants with a negative drug and/or alcohol test result will be considered for employment. I also understand that if after testing has occurred and I decline the offer of employment, I will be fully responsible for reimbursing Petersen's the cost of the test.
PRE-EMPLOYMENT EEO DATA FORM: CONFIDENTIAL
Petersen Incorporated is a Government contractor subject to Executive Order 11246, and to the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended. These regulations require Government contractors to take affirmative action. The following information will assist us in an appropriate position. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. Information you submit will be kept confidential except to government officials engaged in enforcing laws administered by OFCCP.
I voluntarily agree to submit EEO data
I choose not to submit EEO data. * Note: Submiting EEO data is not required and will not effect whether one is or is not hired.*
Gender:
Female
Male
Veteran Status:
Not a Veteran
Vietnam Era Veteran
Other Covered Veteran (served on active duty during a war or in a campaign or expedition for which a campaign badge has been authorized)
Race or Ethnic Group:
White: (Not of Hispanic Origin) All persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.
Black: (Not of Hispanic Origin) All persons having origins in any of the Black racial groups of Africa.
Hispanic: All persons of Mexican, Puerto Rican, Cuban, Central or South America, or other Spanish culture or origin, regardless of race.
Asian or Pacific Islander: All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands.
American Indian or Alaska Native: Persons having origins in the original peoples of North America and who maintain cultural identification through tribal affiliation or community recognition.

I have had an opportunity to have my questions about this statment's content and intent answered and understand its terms.
Selecting the submit button is equivalent to signing this document.