Application Form

REMPAC FOAM CORPORATION

2005 STARLITE DRIVE LUMBERTON, NC 28358

Phone (910) 737-6557

Fax (910) 737-6557

Phone (910) 737-6557

Fax (910) 737-6657

                            Name
                        
                            Last Name
                        
                            First Name
                        
                            Middle Name

Date of Birth

                            Present Address
                        
                            Number
                        
                            Street
                        
                            City
                        
                            State
                        
                            Zipcode

                            Social Security Number
                            
                            (For tax purpose only)

                            Email Address
                        
                            Telephone

Educational Background

Type of School	School Name	Location	Years Completed	Major & Degree
High School
College
Bus. or Trade School
Professional School

Professional References (Other than relatives)

Name	Telephone	Position	Company

EMPLOYEE REFERAL PROGRAM

Name

Phone

Work Experience (Please list your work experience for the past ten years, beginning with the most recent)

Company	Last Supervisor	Last Salary	Start Date	End Date
Address	Last Supervisor	Last Salary	Start Date	End Date
Phone	Job Title
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, and advancements or promotions earned while you worked at this company

Add More

Position Applied For

Desired Salary

Employment Desired

Full-Time

Part-Time

Full or Part-Time

Days / Hours available to work

No Preference

Have you ever been convicted of a crime?

Yes

If yes, explain the number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.

A conviction will not necessarily bar your employment, but will be considered in light of all factors, such as the nature and gravity of the offense, the time passed since conviction or completion of sentence, and the nature of the job sought.

Are you a protected veteran?

Yes

Have you ever been in the armed forces?

Yes

Are you an American Citizen or alien lawfully authorized to work in the United States

Yes

If your answer is NO, please explain

An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying.

PLEASE READ CAREFULLY

APPLICATION FORM WAIVER

In exchange for the consideration of my job application by Rempac Foam Corporation (hereinafter called “the Company”), I agree that:

Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they many exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of Rempac Foam Corporation, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the Management of the Company. Both the undersigned and Rempac Foam Corporation may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits.

I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contract.

I also understand that (1) the Company has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations.

Upon written request from me, the Company, will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act.

I further understand that my employment with the Company 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 the Company is terminable at will for any reason by either party.

“I understand that this application for employment will be considered only for 90 days from date it is submitted. Should I wish to be considered for employment beyond this time period. I must submit a new application.”

I agree with the Application Form Waiver and confirm that the details given in the form are true, complete and accurate.