To ensure proper processing of this application,
please write legibly and provide complete
information.
PERSONAL INFORMATION:
Date:_________________________________________________
Diploma or GED
Criminal Records
Ref #1
Ref #2
Ref #3
Ref #4
Ref #5
FOR OFFICE USE ONLY
Social Security Number:__________________________________
Name:________________________________________________________________________________
Last
First
Middle
Address:_______________________________________________________________________________
Street
City
State
Zip
Daytime Phone:________________________________Evening Phone:____________________________
What is the best time to reach you by phone?__________________________________________________
Are you 18 years old or older? YES_____ NO______
Do you use tobacco products? YES_____NO_____
Are you legally eligible for employment in the United States?
Have you ever been convicted of a felony? YES______
YES______
NO______
NO______ If “yes”, when?_________________
EMPLOYMENT DESIRED: Shift preferred: 2nd_____ (3:00 pm -11:20 pm) 3rd_____ (11:00 pm -7:20 am)
Position:___________________________ How much notice do you need to give?____________________
Are you employed now?______________ May we contact your present employer?____________________
Have you ever worked at Custom-Pak? YES______ NO______ If “yes”, when?____________________
If “yes”, why did you leave employment?______________________________________________________
If “no”, have you ever applied to Custom-Pak? YES______ NO______ If “yes”, when?_______________
Have you ever worked in a “team” environment? YES______ NO_______ If “yes’, please explain.______
___________________________________________________________________________________
ACTIVITIES:
Are you involved with any volunteer community activities or services? If “yes”, what”___________________
______________________________________________________________________________________
Do you think you have mechanical ability? If “yes”, please explain._________________________________
______________________________________________________________________________________
Are you involved in any strenuous physical activities that would prepare you for working here? If “yes”,
please explain._________________________________________________________________________
______________________________________________________________________________________
Emergency contact:_____________________________________________________________________
Relationship:____________________Daytime phone:________________Evening Phone:______________
EDUCATION:
Name of school, address, city & state (or phone number) Please
complete a release form for all schools listed.
Did you graduate?
Yes
No
Special subjects studied or activities
or interests in school.
High School
GED School
College
Business or
Trade School
PERSONAL REFERENCES:
Name
Give names and relationship of people who have known you for at least 2 years. Put an * by their name if
they work at Custom-Pak.
Address, city, state, zip and phone #
Relationship
Years known
I authorize the investigation of all statements contained herein. I authorize the references listed on this application to give CustomPak any and all information concerning my previous employment or education and any pertinent information they may have,
personal or otherwise, and release all parties from all liability for any damage that result from furnishing such information to
Custom-Pak. I understand and agree that if hired, falsification of this information will result in immediate termination. I further
understand and agree, that if hired, my employment is for no definite period of time and may, regardless off the date of payment of
wages, be terminated at any time without prior notice.
Signature:_______________________________________________________________Date:____________________________________
EMPLOYMENT: Please list below your current and/or past employers, starting with the current.
Ref
Dates (from/to)
Month/Year
Business name with complete address
and phone number
Wage
Number of
hours
per week
Position held, including brief
description of tasks
Reason for leaving
Please explain any
gaps in time
Comments:
Comments:
Comments:
Comments:
Comments:
All the facts contained in this application must be true and complete. If you are hired by Custom-Pak, falsified information or
statements, or deliberate omissions on this application will result in immediate termination.
WORK REFERENCE FORM
INSTRUCTIONS: Applicant should complete one of these forms for each current or former employer listed
on your application. Incomplete information may result in application being delayed or denied.
Company Name:_________________________________Phone #:____________________________
Address:__________________________________________________________________________
City:______________________________________State:________________Zip:________________
Contact:___________________________________Fax #:__________________________________
Dates of Employment:__________________________to____________________________________
Position(s) held:____________________________________________________________________
I authorize Custom-Pak to make any investigation of my personal or employment history that is
applicable to the position for which I have applied. I further authorize the release of any requested
information regarding my work ability, work history or attendance. I hereby release Custom-Pak and
all other providers of information from any liability as a result of releasing or receiving this
information.
Applicant’s signature:_________________________________Date:_______________________
Applicant Name (print):_______________________________________________________________
Social Security Number:______________________________________________________________
APPLICANT STOP HERE
The above-named person has applied for a position with Custom-Pak. The information you provide will be
held in strict confidence. Your cooperation is greatly appreciated. This form may be mailed back to: HR
Dept., Custom-Pak, Inc., 86-16th Ave. No., Clinton, IA 52732, faxed to 563-244-5362 or e-mailed to
andrea.lawrence@custom-pak.com. Thank you.
Dates of Employment:__________________________to_____________________________________
Position(s) held:_____________________________________________________________________
Did this person ever receive disciplinary actions? YES ______ NO______
Did this person give adequate notice when leaving your employment? YES ______ NO______
Would you rehire this person (if your policy allowed)? YES ______ NO______
How would you rate their overall job performance?
____Excellent
Reason for leaving:
_____Good
_____Average
______Quit Voluntarily
_____Poor
______Terminated
_____Unacceptable
______Laid Off
Completed by:____________________________Title:____________________Date:_______________
WORK REFERENCE FORM
INSTRUCTIONS: Applicant should complete one of these forms for each current or former employer listed
on your application. Incomplete information may result in application being delayed or denied.
Company Name:_________________________________Phone #:____________________________
Address:__________________________________________________________________________
City:______________________________________State:________________Zip:________________
Contact:___________________________________Fax #:__________________________________
Dates of Employment:__________________________to____________________________________
Position(s) held:____________________________________________________________________
I authorize Custom-Pak to make any investigation of my personal or employment history that is
applicable to the position for which I have applied. I further authorize the release of any requested
information regarding my work ability, work history or attendance. I hereby release Custom-Pak and
all other providers of information from any liability as a result of releasing or receiving this
information.
Applicant’s signature:_________________________________Date:_______________________
Applicant Name (print):_______________________________________________________________
Social Security Number:______________________________________________________________
APPLICANT STOP HERE
The above-named person has applied for a position with Custom-Pak. The information you provide will be
held in strict confidence. Your cooperation is greatly appreciated. This form may be mailed back to: HR
Dept., Custom-Pak, Inc., 86-16th Ave. No., Clinton, IA 52732, faxed to 563-244-5362 or e-mailed to
andrea.lawrence@custom-pak.com. Thank you.
Dates of Employment:__________________________to_____________________________________
Position(s) held:_____________________________________________________________________
Did this person ever receive disciplinary actions? YES ______ NO______
Did this person give adequate notice when leaving your employment? YES ______ NO______
Would you rehire this person (if your policy allowed)? YES ______ NO______
How would you rate their overall job performance?
____Excellent
Reason for leaving:
_____Good
_____Average
______Quit Voluntarily
_____Poor
______Terminated
_____Unacceptable
______Laid Off
Completed by:____________________________Title:____________________Date:_______________
SCHOOL RECORD INFORMATION RELEASE FORM
Custom-Pak requires all new employees to have a high school diploma or a GED. We are requesting
verification that the job applicant listed below has received a high school diploma or GED from your facility.
You may return this form by mail to: HR Dept., Custom-Pak, Inc.,
86-16th Ave. No., Clinton, IA 52732; fax it to: 563-244-5362 or e-mail your response to:
andrea.lawrence@custom-pak.com. Transcripts are not required. Thank you for your time and cooperation.
APPLICANT COMPLETE ONLY TO DOTTED LINE.
Applicant’s current name: __________________________________________________
Applicant’s Social Security Number:
_________________________________________
Applicant’s name when in school (if different): __________________________________
Name of High School or GED School:
Address or fax # of school:
________________________________________
_______________________________________________
Year of Graduation:_________________________
Date of Birth:_________________
I authorize the above-named educational facility to provide Custom-Pak, Inc. with the
information requested. I understand this information will be used as one of the factors
determining my eligibility for employment.
Applicant’s Signature:________________________________Date:______________
This individual DID received a high school diploma or GED.
This individual DID NOT receive a high school diploma or GED.
School Official’s Signature:_____________________________Date:________________
CUSTOM-PAK PRE-EMPLOYMENT DRUG AND ALCOHOL TESTING POLICY
June 1, 1998
Custom-Pak has a vital interest in maintaining safe, healthy and efficient working conditions for its
employees. Being under the influence of a drug or alcohol on the job may pose serious safety and health
risks not only to the user, but to all those who work with the user. The possession, use or sale of an illegal
drug or alcohol in the workplace is prohibited.
With these basic objectives in mind, Custom-Pak has established the following policy:
It is the policy of Custom-Pak to require all prospective employees to take pre-employment drug/alcohol
screening at the Company's expense, which includes urine and/or hair analysis to determine the presence of
alcohol, illicit drugs or controlled substances.
Tests will be conducted at A.R.T. Chiropractic, Medical Associates, Mercy Hospital, Genesis Hospital or
other facilities as authorized by Custom-Pak. A test time will be set up for each applicant by the Personnel
Department. Failure to report to the test site within fifteen (15) minutes of the scheduled appointment,
without notification to the Company, might result in the job offer being withdrawn.
Results will be given to the Vice-President of Personnel or other designated Custom-Pak representative and
will be strictly confidential.
In the event the analysis discloses the presence of illicit drugs or controlled substances, a second test shall
be conducted on the original specimen to confirm the results of the first analysis. If the confirmation test
confirms the results of the first analysis, the applicant shall receive no further consideration for employment.
If the test specimen submitted is found to be adulterated, or the applicant refuses to submit to testing, the
result will be a withdrawal of any job offer made and employment denied to the prospective employee.
The drugs to be tested may include Marijuana, Cocaine, Opiates (including morphine and codeine),
Phencyclidine, Amphetamines (including Methamphetamine) and alcohol.
________________________________________________________________________________________
CUSTOM-PAK CONSENT FOR TEST AND RELEASE OF INFORMATION
I hereby consent for Custom-Pak, or any medical facility, laboratory or medical person designated by the
Company, to collect urine and/or hair samples from me and to conduct medical tests to determine the
presence of alcohol, illicit drugs or controlled substances in my body. I understand that I have the option of
providing any information that may be considered relevant to the test, including identification of prescription
or non-prescription drugs currently or recently used. In addition, I hereby give my consent for the release of
the test results and other relevant medical information to Custom-Pak authorized personnel.
Applicants will be specifically notified of the drug test results provided the applicant submits a written request
for such results within fifteen days from the date the employer provided the applicant with notice of the
results of a drug or alcohol test.
My signature below acknowledges that I have read and understand the above and hereby agree to accept
the same.
Applicant's Signature:____________________________________
Date:____________________________
Witness's Signature:_____________________________________
Date:___________________________
EEO QUESTIONNAIRE
This is a voluntary questionnaire. This questionnaire provides us with general information about your
age, race, and sex. We have added some questions at the bottom that help us improve our applicant
process.
Thank you for your cooperation!
Race:
□White-Not of Hispanic Origin
□Hispanic
□American Indian or Alaskan Native
□Black-Not of Hispanic Origin
□Asian or Pacific Islander
Age:
□18-22
□23-30
□31-40
Sex:
□Male
□41-50
□51-60
□Over 60
□Female
How did you find out we were taking applications? You may mark more than one.
□Newspaper
□Friend or relative told me.
□Walk in
□Internet/Web site
□Job Service
Do you have any suggestions on how we can improve our application process?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
________________________________________________________