Employment Application

Greenberry Industrial is an equal opportunity employer with equal access to programs, services and employment available to all persons. Applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department.

Basic Information

Position Applied for: Millwright Other Pipefitter Project Engineer Project Manager Quality Assurance Coordinator Welder	Date of Application:
Referral source: WebsiteAgencyWalk-inEmployment DepartmentEmployeeOther Name of Source if Applicable:

Name:	Last	First	Middle
Address:	Street	City	Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State	Zip code
Phone:	Home	Cell	Work
Contact Information: Best time to call: AMPM May we contact you at work: YesNo

Are you a United States Citizen or legally authorized to work in the United States?	YesNo
Are at least 18 years of age or able to furnish a valid work permit?	YesNo
Have you ever been employed by Greenberry Industrial, Construction or Tank and Iron? If yes, when was the last time you worked for us?	YesNo
Have you ever applied to Greenberry Industrial, Construction or Tank and Iron? If yes, when was the last time you applied?	YesNo
Type of Employment Desired: * Full-timePart-timeTemporarySeasonalInternship
When are you available for work? Are you willing to work overtime? YesNo
Are you willing to relocate if the job requires it? YesNo Are you willing to travel for work? YesNo
Have you ever been bonded? YesNo Do you have a TWIC card? YesNo
If the job requires driving, do you have a valid driver’s license? YesNo License #: State: Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Have you ever been convicted of a crime other than minor traffic infractions in the last seven (7) years? YesNo If yes, explain:

Employment History

Provide the following information for your past and current employers, assignments or volunteer activities; starting with the most recent (use additional sheets if necessary) Explain any gaps in employment in the comment section below.

Current or Most Recent Employer

Name:	Dates Employed: From: To:
Address:	Street	City	Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State	Zip code
Phone:		May we contact for reference? YesNo
Job Title: Reason for leaving: Hourly Rate/Salary: Start: End:
Immediate Supervisor and Title:
Summary of the type of work performed and job responsibilities:

Previous Employer

Name:	Dates Employed: From: To:
Address:	Street	City	Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State	Zip code
Phone:					May we contact for reference? YesNo
Job Title: Reason for leaving: Hourly Rate/Salary: Start: End:
Immediate Supervisor and Title:
Summary of the type of work performed and job responsibilities:

Previous Employer

Name:	Dates Employed: From: To:
Address:	Street	City	Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State	Zip code
Phone:					May we contact for reference? YesNo
Job Title: Reason for leaving: Hourly Rate/Salary: Start: End:
Immediate Supervisor and Title:
Summary of the type of work performed and job responsibilities:

Education

Name of School Attended	Graduated	Degree/Diploma
	YesNo
	YesNo
	YesNo
	YesNo

Skills and Qualifications

Summarize any special training, skills, licenses and/or certificates that may qualify as being able to perform job-related functions in the position for which you are applying:

Professional, Trade, Business and Civic Associations

Organization	Office Held

Special Accomplishments, Publications and Awards

List any special accomplishments, publications, awards, etc. Exclude any information which would reveal gender, race, religion, national origin, age, color, disability or any other protected status:

References

List three work related or personal references who are not related to you and are not a previous supervisor.
Name	Phone	Years known

Additional Information

List any additional information you would like us to consider:

List resume and cover letter you would like us to consider:

You have 3000 characters remaining

* I understand that if I am employed by Greenberry, any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of my employment upon discovery.

* I give the employer the right to contact and obtain information from references, employers, educational institutions, and to any other relevant organization to verify the accuracy of the information contained in this application. I hereby release from liability the employer and its representatives for seeking, gathering and using such information and all other persons, corporations or organizations for furnishing such information.

The employer does not unlawfully discriminate in employment and no question on this application is used for purpose of limiting or excusing any applicant from consideration for employment as prohibited by local, state and federal law.

This application is current for only 60 days. At the end of 60 days, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to fill out a new application.

* If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice; and the employer reserves the same rights and may terminate my employment at any time with or without cause or prior notice except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that only an authorized representative of the company has the authority to make any assurances to the contrary. I further understand that any such assurances must be in writing and signed by the authorized representative before they are considered valid.

* I understand it is the Company’s policy not to refuse to hire a qualified individual with a disability because of that person’s need for a reasonable accommodation as required by the ADA.

* I understand that if I am hired I will be required to provide proof of my right to legally work in the United States.

* I understand that Greenberry is a drug and alcohol free workplace and as such I must pass a pre-employment physical and drug screen prior to performing any work for the Company (the Company will schedule and pay for these exams once you have been offered and accepted a position with Greenberry. I further understand that all employees of Greenberry are subject to random drug testing and continued employment is subject to the employee’s ability to participate in this process and to pass these tests.

* I represent that I have read and fully understand the above statements and seek employment under these conditions. I further attest that all statements and information provided in this application are true and accurate to the best of my knowledge.

Date: