.: Genesis Systems Group, LLC :.

Automotive Contract Manufacturing Industrial Automation OEM

Application for Employment

Please fill out the form below.

Please provide the following information:
First Name:
Last Name:
Company:
Address:
City:
State/Province:
Zip/Postal Code:
Country:
Phone Number:
E-mail:
Position applied for:
Salary desired:
How were you referred to this company?
Date available for work?
Have you ever been employed by this company?
When?

Are you over the age of 18?:	Yes No
Were you ever convicted of a felony?:	Yes No

School:	Name & Location	Course of Study	Did you graduate?	List diploma or degree
High			Yes No
College			Yes No
College			Yes No

OTHER Business College, Other Special Courses (include Special Military Training, Post Graduate).

Area of Specialization or Major Interest

List Business or Industrial Equipment Operated

List name, address & phone number of previous employers with most recent employer first. If you wish to list more than four jobs ask for continuation form.		From	To	Immediate Supervisor	Last Salary (Hourly, Monthly or Yearly)
Job Title:
Employer Name:
Phone:
Address:
Duties:
May we contact?:	Yes No
Reason for leaving:

Job Title:
Employer Name:
Phone:
Address:
Duties:
May we contact?:	Yes No
Reason for leaving:

Job Title:
Employer Name:
Phone:
Address:
Duties:
May we contact?:	Yes No
Reason for leaving:

Summarize prior relevant experience and fill in periods of unemployment or periods not accounted for above. Also provide any information that may be pertinent to the position applied for

READ THIS SECTION PRIOR TO PROVIDING SIGNATURE BELOW. I understand that my employment can be terminated at any time and for any reson, at the option of either the company or myself. I understand that no one has any authority to enter into any agreement for employment for any specified period of time or to make any agreement contrary to the foregoing, except for a written employment agreement signed by an officer of this company. I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete. I understand that any false or misleading representations or omissions may disqualify me from further consideration for employment and may result in discharge if discovered at a later date. I understand that prior to employment, I must submit to drug testing to detect the use of illegal drugs. I hereby authorize persons, schools, my current employer (if applicable) and previous employers and organizations named in this application (and accompanying resume, if any) to provide this company with any relevant information regarding an employment decision. I release all such persons and this company from any liability regarding the provision or use of such information.
Date:
Signature: