English Application

PERSONAL INFORMATION

First Name

Last Name

Telephone Number

Alternate Number

Address

City

State

Zip Code

If you are under 18 years of age, please provide date of birth:

Position Applied For
Plant ManagerProduction SupervisorLab TechnicianMaintenanceForklift OperatorProduction WorkerFormulatorShipping & Receiving Clerk
Salary Expected

Per HourPer Year
EMPLOYMENT QUESTIONNAIRE
Are you legally entitled to work in the United States?
YesNo
How were you referred to our company?

Can you perform the essential functions of the position for which you have applied?
YesNo
If not, please explain:

Have you ever been convicted of a crime, excluding misdemeanors and summary offenses, in the past ten years which has not been annulled, expunged, or sealed by a court?
YesNo
If so, please describe in full:

Have you ever applied to work with our company before?
YesNo
If so, when?

Have you ever worked for our company before?
YesNo
If yes, when and at what location?

Can you work overtime?
YesNo
On what date would you be available to work?

EDUCATION
(Please list all schools attended. Circle The Highest Level Completed)
High School
9101112
High School (School Name and Address)

Number of years attended

Did you receive a diploma?
YesNo
College
12345+
College (School Name and Address)

Number of years attended

Degree (if applicable)

Major

Graduate (School Name and Address)

Number of years attended

Degree (if applicable)

Major

Other (School Name and Address)

Number of years attended

Degree (if applicable)

Major

List any other training and skills that you feel are relevant to the position for which you are seeking

MILITARY RECORD
Are you a veteran of U.S. military service?
YesNo
If so, what branch?

Dates of Active Service
Start

End

EMPLOYMENT RECORD (List most recent position first)
Employer Name

Employer Address

Start Date

End Date

Job Title

Salary

Telephone Number

Supervisor Name

May we contact?
YesNo
Reason for leaving

Employer Name

Employer Address

Start Date

End Date

Job Title

Salary

Telephone Number

Supervisor Name

May we contact?
YesNo
Reason for leaving

Employer Name

Employer Address

Start Date

End Date

Job Title

Salary

Telephone Number

Supervisor Name

May we contact?
YesNo
Reason for leaving

Employer Name

Employer Address

Start Date

End Date

Job Title

Salary

Telephone Number

Supervisor Name

May we contact?
YesNo
Reason for leaving

Please list all periods of unemployment exceeding three (3) months

I CERTIFY THAT THE INFORMATION CONTAINED IN THIS APPLICATION IS CORRECT TO THE BEST OF MY KNOWLEDGE, AND UNDERSTAND THAT PROVIDING FALSE INFORMATION ON THIS APPLICATION OR OMISSION OF CLEARLY RELEVANT INFORMATION IS GROUNDS FOR DISQUALIFICATION FROM FURTHER CONSIDERATION OR FOR DISMISSAL OF EMPLOYMENT. I UNDERSTAND THE DREXEL CHEMICAL COMPANY MAY CONTACT BY PREVIOUS EMPLOYERS TO VERIFY ANY INFORMATION CONTAINED IN THIS APPLICATION, AND RELEASE DREXEL FROM ANY LIABILITY WHATSOEVER THAT MIGHT BE INCURRED IN OBTAINING THIS INFORMATION. I AGREE TO CONFORM TO THE RULES AND REGULATIONS OF THE COMPANY, AND UNDERSTAND THAT MY EMPLOYMENT CAN BE TERMINATED, WITH OR WITHOUT CAUSE, AND WITHOUT OR WITHOUT NOTICE, AT ANY TIME, AT THE DISCRETION OF EITHER THE COMPANY OR MYSELF.
Signature
Click to accept Signature
Date

By applying for a job with Drexel Chemical Company, you agree that we may use your personal data for employment purposes. Providing your personal data to Drexel Chemical Company is voluntary. If, however, you do not provide all of the data that is requested in your application, our ability to consider you for employment may be limited. REV. 1/2020

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