Employment Application

Last Name: First Name: Middle Name: Maiden Name:
Mailing Address:
City: State: Zip Code:
Cellular Phone Number: Home Phone Number:
Your Email Address:
Positions applying for:
1.
2.
Preferred Location:
Morristown
Kodak
No Preference

Have you ever been employed at OTICS previously?
Yes
No

Dates employed:

Have you previously applied with OTICS before?
Yes
No

Date applied:

EDUCATION & TRAINING

Name and Location of last High School Attended
Graduated High School?
Yes
No
Did you obtain a GED/HSE?
Yes
No
Name and Location of College or University
Major
Minor
Type of Degree

Other Schools or Training (Trade, Vocational, Armed Forces, or Business) Give names and location of each school, subjects, studies, certificates, and any other pertinent data.
Special Qualifications and Skills (licesnes, skills with machines, computer skills, honors, awards and fellowships.

OTHER INFORMATION

Can you work both 1st and 3rd shift?
Yes
No
Are you willing to work overtime: Yes
If job requires, do you have a valid driver's license?
Yes
No
Driver License Number
Type
State issued

EMPLOYMENT HISTORY - Begin with your most recent job.

Name of Employer 1
 Name of Supervisor
Job Title
Dates worked
From: To: 		Pay
$Per
Address:
City: State: Zip Code:
Phone Number: Reason for Leaving:
Duties performed:
Name of Employer 2
 Name of Supervisor
Job Title
Dates worked
From: To: 		Pay
$Per
Address:
City: State: Zip Code:
Phone Number: Reason for Leaving:
Duties performed:
Name of Employer 3
 Name of Supervisor
Job Title
Dates worked
From: To: 		Pay
$Per
Address:
City: State: Zip Code:
Phone Number: Reason for Leaving:
Duties performed:
PERSONAL REFERENCES: List the names of three references, no relatives, the employer may contact.

1) Name
Telephone
Occupation
2) Name
Telephone
Occupation
3) Name
Telephone
Occupation


Are you eligible to work in the United States?
Yes
No
Have you ever pleaded guilty or no contest to or been convicted of a crime?
Yes
No
Dates/Details:
Answering "yes" to the question above will not necessarily disqualify you for employment.

Certification
I certify that all of the statements made in this application are true, complete and correct to the best of my knowledge and belief, and are made in good faith. I authorize, without reservation, the employer to contact and obtain information from all references and to otherwise verify accuracy of all information provided by me in this application, resume or job interview.
Name:
Date:

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