Employment Application

KibbeChem, Inc. is an equal opportunity employer. Applicants are considered for employment without regard to race, color, religion, sex, age, disability, citizenship status, national origin, veteran status, or any other basis prohibited by law. KibbeChem, Inc. will comply with its obligation to provide reasonable accommodation to qualified individuals with disabilities.

* Required Information

Personal Information

Last Name*:

First Name*:

Middle Name:

Home Phone*:

E-mail Address:

Last four digits of your Social Security #:

Street Address*:

City*:

State*:

Zip*:

If you have resided at your present address less than three years, list your prior address:

Street Address*:

City*:

State*:

Zip*:

Position(s) Desired

Type of Position Desired:

Have you ever filed an application with us before? If yes what dates?:

Have you ever worked for Kibbechem Inc. before? If yes when?:

What prompted you to apply for employment with KibbeChem, Inc. (e.g., newspaper advertisement, recommendation, etc.)?:

Are you legally authorized to work in the United States?:

Verification of eligibility to work in the United States is required at the time of hire.

Are you over the age of 18?:

Available to work

Full Time:

Part Time:

Temporary:

Weekends:

Can you travel if a job requires it?:

On what date would you be available to begin work:

Do you have any commitments or obligations with any school or other employer, business or organization that might affect your availability to work if you were hired?:

If yes, please explain:

Have you been convicted of or pled guilty to a felony or a misdemeanor other than a minor traffic-related infraction? (A conviction or plea will not automatically disqualify applicant from consideration or employment.):

If yes, state the nature of the conviction or plea, the date, and explain:

References

List the name, address, and telephone number of three business/work references.

	Name	Address	Telephone No.
Reference #1
Reference #2
Reference #3

Education

	School Name / Location	Graduated Yes / No Years Attended	Major Pursued / Degree Earned
High School or GED
College or University
Business, Trade or Technical School or College
Correspondence, Post Graduate or Special School or College

List any special job-related skills and qualifications acquired through education, employment, apprenticeship, training or seminars that are applicable to the type of position you are seeking.:

Employment Experience

Start with your most recent or present employer, and provide all employers leaving no gaps in your work history for the last 3 places of employment. Include any military service assignments that may cause a gap.

Employer #1

Employer Name:

From (Mo/Yr):

To (Mo/Yr):

Starting Payrate:

Final Payrate:

Street Address:

City:

State:

Zip:

Phone:

Job Title:

Immediate Supervisor:

Work performed / Job Duties:

Reasons for leaving:

Employer #2

Employer Name:

From (Mo/Yr):

To (Mo/Yr):

Starting Payrate:

Final Payrate:

Street Address:

City:

State:

Zip:

Phone:

Job Title:

Immediate Supervisor:

Work performed / Job Duties:

Reasons for leaving:

Employer #3

Employer Name:

From (Mo/Yr):

To (Mo/Yr):

Starting Payrate:

Final Payrate:

Street Address:

City:

State:

Zip:

Phone:

Job Title:

Immediate Supervisor:

Work performed / Job Duties:

Reasons for leaving:

May we contact the employers you have listed?:

If no, indicate which one(s) you do NOT wish to us to contact and state the reasons why you prefer that we do not contact the employer(s):

Have you ever been discharged or asked to resign from any position?:

If yes, please state the employer and dates of employment, and reasons.:

Applicant's Statement

Please indicate that you have read and understand each paragraph of the following Applicant’s Statement by placing your initials beside each paragraph.