EMPLOYMENT APPLICATION INSTRUCTIONS
IMPORTANT: PLEASE READ INSTRUCTIONS CAREFULLY
A completed application is required for all positions. Information from the
application will be used to determine if minimum qualifications are met. Incomplete
applications will not be accepted; false or evasive answers on the application may
result in loss of employment opportunities.
The application you submit will be reviewed and if, based upon the information you
have supplied, there is a need to schedule you for a personal interview, you will be
contacted by telephone or email. If, however, we are unable to consider your
application, you will receive no further notice. Applications are valid for only thirty
(30) days and if you have not received a response during this time period, you are
welcome to re-apply. Due to the large volume of employment inquiries, we regret
that we are unable to provide a more personal response to your application.
THIS ORGANIZATION PARTICIPATES IN E-VERIFY
FEDERAL LAW REQUIRES ALL EMPLOYERS TO VERIFY THE IDENTITY AND
EMPLOYMENT ELIGIBILITY OF ALL PERSONS HIRED TO WORK IN THE UNITED STATES
Please download and complete the attached employment application. Then email
your completed application to us at usjobs@sigvaris.com
We thank you for your interest in employment with Sigvaris.
SIGVARIS will contact you regarding employment. Please do not
call regarding the status of your application.
Employment Application
Document Number:
4.161
Revision:
05/16/2016
(PLEASE PRINT AND COMPLETELY ANSWER ALL QUESTIONS)
SIGVARIS, Inc., (“Company”), fully subscribes to the principles of Equal Employment Opportunity. It is our policy to provide
employment, compensation, and other benefits related to employment based on merit, without regard to race, color, religion,
national origin, age, sex, veteran status, genetic information, disability or any other basis prohibited by federal, state or local law. In
accordance with requirements of the Americans with Disabilities Act and applicable state laws, it is our policy to provide reasonable
accommodation upon request during the application process to eligible applicants in order that they may be given a full and fair
opportunity to be considered for employment. As an Equal Opportunity Employer, we intend to comply fully with applicable federal
and state employment laws and the information on this application will only be used for purposes consistent with those laws.
SIGVARIS, Inc. is a Drug Free Workplace.
POSITION APPLIED FOR:
DATE: ______________________________
PERSONAL DATA
Name ____________________________________________________________________________________________________
Last
Middle
First
Last 4 digits of Social Security number:
Street Address _____________________________________________________________________________________________
City______________________________________ State___________________________ Zip Code________________________
Telephone (H) _______________________________________ (C) __________________________________________________
Email address:
Are you at least 18 years of age or older? (If no, you may be required to provide authorization to work.)
□ Yes □ No
Are you legally authorized to work in the United States? □ Yes □ No
Will you now or in the future require sponsorship for employment visa status (e.g., H-1B status)? □ Yes □ No
Are there any days, shifts or hours you will not work?
□ Yes □ No
If yes, please explain _______________________________________________________________________________________
Will you work overtime if required?
□ Yes □ No
Date you are available to start work __________________________ Hourly Rate/Salary desired _________________________
REFERRAL SOURCE
How did you learn of the Company? __________________________________________________________________________
If referral, who were you referred by? ________________________________________________________________________
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Employment Application
Have you ever applied or worked for the SIGVARIS, Inc. before?
□ Yes □ No
Document Number:
4.161
Revision:
05/16/2016
If Yes, provide dates:_______________________
DRIVING RECORD
(Answer only if driving is a requirement of the job for which you are applying. (e.g. warehouse personnel)
Do you have a valid driver’s license? □ Yes □ No State _________________ License No _________________________________
Have you had any tickets?
□ Yes □ No
If Yes, please explain: ________________________________________________________
___________________________________________________________________________________________________________
Do you have any DUI or DWI convictions?
□ Yes □ No
If Yes, please state when you were convicted and explain: ______________
___________________________________________________________________________________________________________
EDUCATION
Describe any educational degrees, skills, training or experience you believe are relevant to the job applied for:
Name, City and State of
Institution
Graduated
Yes or No
If No, Degree
Credits Earned
Major
Minor
Grade
Point/Overall
GPA
High School
College or University
Technical/GED
Licenses/Certification/Other
EMPLOYMENT HISTORY
Please complete for all full-time and part-time employment. Include your last ten (10) years of employment history, including
periods of unemployment, starting with the most recent and working backwards in time. Incomplete information could disqualify
you from further consideration.
Company Name_______________________________________ Telephone _____________________________________________
Address____________________________________________________________________________________________________
Name of Supervisor________________________________________ May we contact?
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□ Yes □ No
Employment Application
Document Number:
4.161
Revision:
05/16/2016
Dates Employed: From _________________ To___________________ Rate of Pay: Start ____________ Last____________
Job Title and Duties ___________________________________________________________________________________________
Reason for leaving ____________________________________________________________________________________________
Company Name_______________________________________ Telephone _____________________________________________
Address____________________________________________________________________________________________________
Name of Supervisor________________________________________ May we contact?
□ Yes □ No
Dates Employed: From _________________ To___________________ Rate of Pay: Start ____________ Last____________
Job Title and Duties ___________________________________________________________________________________________
Reason for leaving ____________________________________________________________________________________________
Company Name_______________________________________ Telephone _____________________________________________
Address____________________________________________________________________________________________________
Name of Supervisor________________________________________ May we contact?
□ Yes □ No
Dates Employed: From _________________ To___________________ Rate of Pay: Start ____________ Last____________
Job Title and Duties ___________________________________________________________________________________________
Reason for leaving ____________________________________________________________________________________________
Company Name_______________________________________ Telephone _____________________________________________
Address____________________________________________________________________________________________________
Name of Supervisor________________________________________ May we contact?
□ Yes □ No
Dates Employed: From _________________ To___________________ Rate of Pay: Start ____________ Last____________
Job Title and Duties ___________________________________________________________________________________________
Reason for leaving ____________________________________________________________________________________________
Do you have any special skills, experience and/or training that would enhance your ability to perform the position applied for? If
yes, please explain. ___________________________________________________________________________________________
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Employment Application
Document Number:
4.161
Revision:
05/16/2016
PROFESSIONAL REFERENCES (Please list three persons not related to you who know your qualifications.)
NAME
ADDRESS
PHONE
RELATIONSHIP
CRIMINAL HISTORY
Have you ever been convicted of a criminal offense (felony or misdemeanor)?
□ Yes □ No
If yes, explain 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.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The date of the offense, the nature of the
offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense
to the position(s) applied for may, however, be considered.)
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Employment Application
Document Number:
4.161
Revision:
05/16/2016
APPLICANT’S CERTIFICATION AND AGREEMENT
I hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge. I
understand that any misrepresentations, omissions of facts or incomplete answers in any application document may disqualify me
from further consideration for employment. I further understand that, if employed, any misrepresentations or omissions of facts in
any application document may be cause for my dismissal at any time without prior notice. I consent to and authorize the Company
to contact my former employers, references, and any and all other persons and organizations for information bearing upon my
qualifications for employment. I further authorize the listed employers, schools and personal references to give the Company any
and all information about my previous employment and education, along with any other pertinent information they may have and
hereby waive any actions which I may have against either party(ies) for providing a good faith reference.
I understand that I will be required to qualify for employment based on additional employment criteria, including a pre-employment
drug test and background investigation. If I am offered employment or start work before any required tests are completed, my
employment is contingent on a satisfactory result on all required tests.
I understand that neither the completion of this application nor any other part of my consideration for employment establishes any
obligation for SIGVARIS, Inc. to hire me. If I am hired, I understand that either SIGVARIS, Inc. or I can terminate my employment at
any time and for any reason, with or without cause and without prior notice. I understand that no representative of SIGVARIS, Inc.
has the authority to make any assurance to the contrary.
Signature: ________________________________________________ Date: ____________________________________________
THIS APPLICATION IS VALID ONLY FOR 60 DAYS FROM THE DATE SIGNED ABOVE.
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