First Name *
Last Name *
Address *
City *
State *
Zip *
Phone *
Email *
List all states in which you have lived or resided for the last 10 years:
1. Employer’s Name
Employer’s Phone
Employer’s Location (complete address not necessary)
Supervisor’s Name and Title
Job Responsibilities
Pay Rate
Date Hired
Date Separated
Reason for Leaving
2. Employer’s Name
Employer’s Phone
Employer’s Location (complete address not necessary)
Supervisor’s Name and Title
Job Responsibilities
Pay Rate
Date Hired
Date Separated
Reason for Leaving
3. Employer’s Name
Employer’s Phone
Employer’s Location (complete address not necessary)
Supervisor’s Name and Title
Job Responsibilities
Pay Rate
Date Hired
Date Separated
Reason for Leaving
4. Employer’s Name
Employer’s Phone
Employer’s Location (complete address not necessary)
Supervisor’s Name and Title
Job Responsibilities
Pay Rate
Date Hired
Date Separated
Reason for Leaving
EDUCATION:
College/University (include city & state)
Number of Years Attended
Degree and Major
Please list any scholastic honors, awards, subjects of special study, research, publications and/or thesis:
ADDITIONAL INFORMATION
Position applied for or type of work desired
Date you can start
If yes, please explain
If yes, for each conviction, provide the date and place of conviction and the type of crime, below.
Rate your personal computer skills (1 = Poor, no knowledge; 10 = Proficient, extremely skilled):
Describe the computer systems and programs in which you are experienced:
Describe any specialized training, apprenticeships and/or skills that you possess that you believe are relevant to the
position for which you are applying:
Do you have any other experiences, skills, or abilities that you feel especially qualify you for work with our company?
PROFESSIONAL ASSOCIATIONS, CERTIFICATIONS, OR LICENSES
Please list any professional, trade, business or civic activities in which you have been involved, and offices held. You may
exclude membership or activities which would reveal race, color, religion, creed, sex, gender, national origin, age, ancestry,
disability and/or handicap, or any other legally protected status. Also list any certifications or licenses that you possess,
including the state(s) in which they are valid:
PRE-EMPLOYMENT STATEMENT
PLEASE READ THE FOLLOWING STATEMENT CAREFULLY AND SIGN BELOW. U.S. Bronze Foundry & Machine , I understand, agree and/or
certify to the following:
1. I certify that all information I have provided on this application, and on any other documents submitted with it, is true,
accurate, and complete to the best of my knowledge and belief. I understand that falsification, misrepresentation or
omission of any information on my application, resume, or any other materials, or which I supply during any interviews,
will be justification for withdrawing any offer of employment or, if employed, termination from employment, regardless
of when the falsification, misrepresentation or omission is discovered by the Company.
2. Any offer of employment I may receive from U.S. Bronze Foundry & Machine, Inc. is contingent upon my successful
completion of the company’s total pre-employment screening process. This process may include, but not be limited to,
the following:
Receipt by the company of references that it considers satisfactory;
My satisfactory completion of any post-offer pre-employment medical examination that company may require;
Passing a screening for alcohol and/or drugs. I also understand and agree that, if employed, I may be required to
submit to a medical examination or an alcohol and/or drug screening at any time at the discretion of the Company.
I hereby consent to having the results of any such post-offer pre-employment or post-employment medical exam or
alcohol and/or drug screening disclosed to U.S. Bronze Foundry & Machine, Inc.
3. I hereby grant U.S. Bronze Foundry & Machine, Inc. permission to contact all of my present and former employers and
those individuals I have listed as personal references (unless specifically excluded in writing). I authorize and request
that such employers and references furnish information about my employment record, including a statement of the
reason for the termination of my employment, work performance, abilities, and other qualities, and other qualities
pertinent to my qualifications for employment. Further, and in accordance with the Authorization to Obtain a Consumer
Report, which has been provided me, I authorize U.S. Bronze Foundry & Machine, Inc., or its agent, to obtain
transcripts from all educational institutions I have attended and to conduct whatever additional investigation (e.g.,
educational verification, criminal check, motor vehicle record, and credit check) which may be needed to obtain or
verify information regarding my application, resume, any other materials, or any interviews, or concerning my
qualifications for employment. I hereby release all parties from any and all liability for damages arising from furnishing
the requested information.
4. I also understand that, if hired, my employment is to be “At Will” and that either I or U.S. Bronze Foundry &
Machine, Inc. may terminate my employment at any time, with or without cause, unless the “At Will”
arrangement is modified by a written agreement signed by both me and the owner(s) of the Company.
5. I authorize U.S. Bronze Foundry & Machine, Inc. to deduct and/or withhold from my final paycheck any amounts due and
owing by me for my failures, and to return any Company property and/or to satisfy any financial obligations that I have,
arising or occurring prior to the date of the issuance of my final paycheck.
6. I understand that my application will remain active for 60 days, and that to be considered for a job with U.S. Bronze
Foundry & Machine, Inc. after that, I must reapply.
