Application for Employment

Name*

Email Address*

Home Phone*

Address

Street Address City State ZIP Code

How did you hear about us?

Position You are Applying For

Hourly / Salary Expectation

Summary of Your Professional Experience

Are you authorized to work in the United States Of America?*

Yes
No

Please Attach Resume*

For Equal Employment Opportunity / Affirmative Action Information

Periodic reports made to the government of the following applicant information. Your submission of this information is optional and voluntary. Refusal to provide this information will not eliminate you from consideration of employment or subject you to discharge or disciplinary treatment if hired. This portion of the employment application will not be become part of your applicant file.

Are you disabled?

Yes
No

Are you a Veteran?

Yes
No

Veterans and Other eligible Veterans list campaigns you served in

Are you a Vietnam Era Veteran?

Yes
No

*Served on Active Duty Between 8/5/64 to 5/7/75

Are you a Special Disabled Veteran?

Yes
No

If declaring disability or handicap status, please describe any physical or mental condition you have.

Sex

Male
Female

Race or Ethnic Identity

Hispanic or Latino
White (Not Hispanic or Latino)
Black or African American (Not Hispanic or Latino)
Native Hawaiian or other Pacific Islander (Not Hispanic or Latino)
Asian (Not Hispanic or Latino)
American Indian or Alaskan Native (Not Hispanic or Latino)
Two or More Races (Not Hispanic or Latino)

Digital Signature Acknowledgement

By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

Signature

Date

Application for Employment

For Equal Employment Opportunity / Affirmative Action Information

Dearborn Mid-West Company since 1947

Over 70 Years of excellence

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