Application

First Name

Last Name

Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Are you legally eligible for employment in the U.S.A?

Yes

If hired, you are required to submit proof of your eligibility to work in the U.S.A.

Are you over the age of eighteen?

Yes

If “NO”, hire is subject to verification that you are of minimum legal age.

Shift Desired

1st

3rd

Have you previously been employed by NVIC/CCC?

Yes

If “YES”, when?

Available Start Date

Please list your job related experiences, skills, or qualifications which will be of special benefit in the job for which you are applying?

Referred to NVIC/CCC by:

Relationship:

Previous Employer Details

Please fill in details about your most recent employers below

Most Recent Employer Name

Date Employed From (Mo/Yr)

Date Employed To (Mo/Yr)

Starting Wage

Ending Wage

Work Description/Responsibilities

Second Most Recent Employer Name

Date Employed From (Mo/Yr)

Date Employed To (Mo/Yr)

Starting Wage

Ending Wage

Work Description/Responsibilities

Third Most Recent Employer Name

Date Employed From (Mo/Yr)

Date Employed To (Mo/Yr)

Starting Wage

Ending Wage

Work Description/Responsibilities

Education

Education – High School Name

Years Completed

Please Read and Sign Below

PLEASE READ AND SIGN BELOW

The facts set forth in my application for employment are true and complete.
I understand that if employed, any false statement on this application may result in my dismissal.
I understand that this application is not and is not intended to be a contract of employment, nor does this application obligate the employer in any way if the employer decides to employ me.
I understand and agree that my employment is “AT-WILL” and can be terminated by either party with or without notice, at any time, with or without reason. No one other than the President of NVIC/CCC has the authority to enter into any agreement for employment for any specified period of time or to make any agreement contrary to the foregoing and then only in writing signed by the President.
I understand that my employment with the NVIC/CCC shall be probationary for a period of ninety (90) days, and further that at any time during the probationary period or thereafter, my employment relation with NVIC/CCC is at-will and may be terminated at any time.
I understand that if I am NOT selected for employment this application will remain in an active status for a period of (90) ninety days and then will be stored for record purposes only for a total of 180 days. Unsuccessful candidates with continued interest in employment must contact a member of Human Resources to be considered for employment.

The Civil Rights Act of 1964 prohibits discrimination in employment because of race, color, religion, sex or national origin. Federal law also prohibits other types of discrimination such as age, citizenship, disability, veteran status, attainment of benefits, and participation in union activities. The laws of most states and many localities also prohibit some or all of the above types of discrimination as well as some additional types including, but not limited to, discrimination based upon ancestry, marital status, parental status, sexual orientation, or source of income. The Fair Credit Reporting Act imposes restrictions with respect to credit data. This list, however, is not exhaustive of the grounds on which discrimination is prohibited.

“Signature of Applicant (Type Full Name)”

Date / Time

By checking this box and typing my name above, I acknowledge that this constitutes my legal electronic signature and that all information provided is true and complete.

NORTH VERNON INDUSTRY CORPORATION

ACKNOWLEDGMENT AND AUTHORIZATION

FOR BACKGROUND SCREENING

I, __________________________, understand and acknowledge that as a condition of working as an employee for NVIC that I must allow a background check to be conducted. This check will include information concerning my arrest record if any. I also authorize NVIC, my employer, to obtain such a report so that I may be placed with employment with them. I further agree, upon request, I must furnish to NVIC a copy of my convictions or non-convictions based on information retained from local law enforcement agencies concerning my arrest record. I understand that if requested I must obtain this record from the court clerk in the county of the conviction. I further agree that I cannot and will not hold NVIC, its employees or any state and local law enforcement agencies responsible for any information provided to NVIC.

I understand that a criminal conviction related to the job in question may result in not being an employee of NVIC. However, a criminal conviction does not result in an automatic termination from NVIC and will be considered only as it relates to the job in question.

“Signature of Applicant (Type Full Name)”

Date / Time

Date of Birth:

Social Security Number

Maiden Name/or Alias:

By checking this box and typing my name above, I acknowledge that this constitutes my legal electronic signature and that all information provided is true and complete.

NORTH VERNON INDUSTRY CORPORATION

DRUG AND ALCOHOL CONTROL PROGRAM

STATEMENT OF SUBSTANCE ABUSE POLICY

I understand that NVIC is a zero tolerance employer with respect to Drug and Alcohol use.

I, ____________________________ agree to submit to testing to be performed by Everside Health for the detection of drugs and/or alcohol as required for employment consideration with NVIC. I give permission for test results to be released to NVIC’s Human Resource Representative.

I understand that positive test results, refusal to be tested or any attempt to affect the test results or test sample will result in withdrawal of my application for employment and/or withdrawal of any provisional employment offer I have received from NVIC.

I agree to hold harmless and release from all claims NVIC and its agents (including the above-named facility/laboratory) from any liability arising in whole or part out of the collection of specimens, testing and the appropriate use of the information from such testing.

“Signature of Applicant (Type Full Name)”

Date / Time

By checking this box and typing my name above, I acknowledge that this constitutes my legal electronic signature and that all information provided is true and complete.