F HR 004 Employment Application

Galloway CompanyEmployment Application Page 1 of 9F-HR-004-C 9/18/2012

This document contains trade secret/confidential commercial information pursuant to 5 U.S.C 552(b)(4)

EMPLOYMENT APPLICATIONGalloway Company 601 South Commercial Street, Neenah, WI 54956 Phone (920) 722-8903 Fax (920) 722-1927

Personal InformationLast Name First Name M.I. Date

Address Driver’s License #

City Zip Code Home Phone

Email Address Other Phone

Positions Applied For: (PLEASE CHECK ONE)Clerical (Specify) Production Worker

Professional (Specify) Technical (Specify)

Managerial (Specify) Other (Specify)

Available:Year Round ______Summer Only ______

Office Use Only:

Contacted: _____________________ Interviewed: ________________________________

Comments:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

If you require any reasonable accommodation to complete this form or any part of the application or selection process, please contact the Personnel Office at 920-722-7741 or fax 920-722-1927. Thank you.

Education & Training:



Education: Elementary High School College/University Post GradSchool Name City, State

Years Completed

Diploma/Degree

Specialized Training, Skills, Extra-Curricular Activities

Character References:Please list (3) persons not related to you, that have known you for at least (6) months, and have knowledge of your character, experience, and ability.Name Occupation

Home Address Business Address

City, State, Zip City, State, Zip

Home/Cell Phone Business Phone

Name Occupation




Name Occupation






EMPLOYMENT EXPERIENCE:Please start with your present of most recent job first.Employer Duties Performed:

Address

City, State, Zip

Job Title

Supervisor

Reason for Leaving

Dates Employed:

Hourly Rate/Salary: May we contact this employer for references?

Employer Duties Performed:

Address

City, State, Zip

Job Title

Supervisor

Reason for Leaving

Dates Employed:




EMPLOYMENT EXPERIENCE CONTINUED:Employer Duties Performed:

Address

City, State, Zip

Job Title

Supervisor

Reason for Leaving

Dates Employed:


Employer Duties Performed:

Address

City, State, Zip

Job Title

Supervisor

Reason for Leaving

Dates Employed:


Please use additional pages if needed.

Please answer the following questions:



Are you 18 years old or over? YES NO

Are you currently employed? YES NO

Are you on layoff, subject to recall?

YES NO

Have you ever been discharged from any position? If yes, state facts & penalty. NO

Have you been convicted of a felony?If yes, state facts & penalty. NO

Do you have friends or family who work for Galloway Company?

If yes, please name employee and state relationship.NO

Are you legally eligible for employment in this country?

YES NO

Are you able to meet the attendance requirements for the position?

YES NO

Will you work overtime if required?

YES NO

Have you ever been employed at Galloway Company before?

YES NO

Date available for work?

NOTICE:Some of the positions at Galloway Company are filled using various selection tests.If the position for which you have applied is filled utilizing selection test, you will receive notice of the time, date, and place. If you require special accommodation, please contact the Personnel Office at (920) 722-7741 at least (7) days prior to the test.

Galloway CompanyVoluntary Affirmative Action Information



Galloway Company is required by State and Federal employment regulations to keep records and make reports to the Equal Employment Opportunity Commission. By answering the questions below, you will assist us in our

reporting requirements. The information is voluntary and will be collected and used for statistical purposes only.

This form will be filed separately from your application and will not be used to discriminate in any way in the employment process.

Name: Date:

Male / Female Position applying for:

ETHIC ORIGIN: Please circle one Hispanic Black White American Indian /Alaskan Native Asian/ Pacific Islander

SPECIAL NOTICE TO VIETNAM ERA VETERANS, DISABLED VETERANS, AND INDIVIDUALS WITH PHYSICAL OR MENTAL DISABILITIES:

Government contractors subject to Vietnam Era Veterans Readjustment Act of 1974 and the Rehabilitation Act of 1973 are required to take affirmative action to employ and advance in employment qualified disabled veterans and veterans of the Vietnam Era, and qualified handicapped individuals.

You are invited to volunteer this information, if you qualify, to assist in proper placement and determining reasonable accommodation. This information will be considered confidential, and refusal to provide this information will not adversely affect your consideration for employment.

IF YOU WISH TO BE IDENTIFIED, PLEASE CIRCLE IF ANY OF THE FOLLOWING ARE APPLICABLE: VIETNAM VETERAN DISABLED VETERAN HANDICAPPED INDIVIDUAL

How did you hear about the job in which you are applying? Please circle all that apply.

Employee or Relative School Employment Agency AdvertisementOther ( Please Explain)______________________________________________________________________________________________________________________

This form is to be completed by applicant - Not for interview purposes - to be filed separately from application.This information is used to satisfy the Affirmative Action requirements of Section 503 of the Rehabilitation Act or necessitated

by another federal law or regulation.

Please list any additional information you would like us to consider:



It is understood and agreed upon that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or discharge from the Galloway Company’s service if I have been employed. Furthermore, I understand that just as I am free to resign at any time, Galloway Company reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of Galloway Company has the authority to make any assurances to the contrary.

I give the Galloway Company the right to investigate all references and to secure additional information about me, if job related. I hereby release from liability the Galloway Company and its representatives for seeking such information and all other persons, corporations, or organizations for furnishing such information.

Galloway Company is an Equal Opportunity Employer. Galloway Company does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant’s consideration for employment on a basis prohibited by local, state or federal law.

This application is current for (1) year. At the conclusion of that time, if I have not heard from the Galloway Company and still wish to be considered for any reported openings, it will be necessary to fill out a new application.

____________________________________ ____________________________Signature of Applicant Date

Situation Questions



1. Describe a situation where you had to make a decision but you did not have all the information you needed.

2. Describe a situation where you found an error in your work. What was the cause? How was it handled?

3. Give an example of a time when you were given a task to accomplish without advance warning.

4. Give a specific example of doing more than required in one of your previous jobs.

5. Describe a situation where you wished you had acted differently with someone at work. What did you do? What happened as a result?

6. Describe a time when you organized your thoughts on a matter of importance to you, and in communicating these to others; you felt you got you points across well.

7. Describe a time when you brought together a group of people to work with each other in some activity or project?



8. Describe a time when you set your sights on a high, demanding goal and achieved it.

9. Give an example of a new idea that you came up with that made a significant contribution to the success of some activity or project.

10. Give an example of an experience where you came to be regarded by other people as a person who could be trusted to listen to them and treat them fairly.

11. Give examples of your involvement in safety and wellness programs at your previous positions.

___________________________________Print Name

____________________________________Signature

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