Apply Online "*" indicates required fields 1Personal2Education3Employment History4Skills, Experience and References5Applicant’s Agreement PersonalName First Middle Last Social Security Number Phone*Email Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code If any records are in another name please list Are you 18 years old or older?* Yes No Birth Date if under 18: MM slash DD slash YYYY Have you been convicted of a felony?* Yes No Note: Conviction will not necessarily disqualify you from employment.If yes, please explainAre you a previous employee of Jasper Rubber?* Yes No Dates of Employment: Do you have a valid Driver’s License?* Yes No Are you re-applying with Jasper Rubber after completing Military Duty?* Yes No Date Available for Employment* MM slash DD slash YYYY If you know of anyone in our employ, State their name(s) and department(s)How did you hear about Jasper Rubber?* Newspaper Friend JRP Employee Jasper Rubber Facebook Jasper Rubber Website Other Please list the Position(s) you would be available for:Apply OnlineWork Preference (check all that apply)* Full Time Part Time Temporary Summer Office Manufacturing Available for:* 1st Shift: 6:00 a.m. – 2:00 p.m. 2nd Shift: 2:00 p.m. – 10:00 p.m. 3rd Shift: 10:00 p.m. – 6:00 a.m. Any Shift EducationHigh School* Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Number of Years Completed*Degree Attained* Yes No Nature of Courses Taken or Degree Attained* Vocational-Technical School Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Number of Years CompletedDegree Attained Yes No Nature of Courses Taken or Degree Attained College Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Number of Years CompletedDegree Attained Yes No Nature of Courses Taken or Degree Attained Graduate School Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Number of Years CompletedDegree Attained? Yes No Nature of Courses Taken or Degree Attained Employment HistoryPresent or Most Recent Employer* Type of Business* Phone*Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employment Start Date* MM slash DD slash YYYY Employment End Date* MM slash DD slash YYYY Starting Position* Starting Salary*Ending/Current Position* Ending/Current Salary*Supervisor's Name* Supervisor's Phone*Describe responsibilities, tasks performed and/or skills used. (Machines, Tools, etc.)*Reason for Leaving/Considering Leaving*May We Contact?* Yes No Add More Experience? Add Another Job Employer Name Type of Business PhoneAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employment Start Date MM slash DD slash YYYY Employment End Date MM slash DD slash YYYY Starting Position Starting SalaryEnding Position Ending SalarySupervisor's Name Supervisor's PhoneDescribe responsibilities, tasks performed and/or skills used. (Machines, Tools, etc.)Reason for Leaving/Considering LeavingMay We Contact? Yes No Add More Experience? Add Another Job Employer Name Type of Business PhoneAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employment Start Date MM slash DD slash YYYY Employment End Date MM slash DD slash YYYY Starting Position Starting SalaryEnding Position Ending SalarySupervisor's Name Supervisor's PhoneDescribe responsibilities, tasks performed and/or skills used. (Machines, Tools, etc.)Reason for Leaving/Considering LeavingMay We Contact? Yes No Add More Experience? Add Another Job Employer Name Type of Business PhoneAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employment Start Date MM slash DD slash YYYY Employment End Date MM slash DD slash YYYY Starting Position Starting SalaryEnding Position Ending SalarySupervisor's Name Supervisor's PhoneDescribe responsibilities, tasks performed and/or skills used. (Machines, Tools, etc…)Reason for Leaving/Considering LeavingMay We Contact? Yes No Skills and ExperienceSummarize special job related skills and qualifications acquired from employment, education or other experiences that may quailify you for a Position with us.State any additional information you feel may be helpful to us in considering your application.Upload a ResumeMax. file size: 20 MB.ReferencesList 3 individuals who are best acquainted with your work performance and/or academic achievement.Name First Last PhoneCompany Name Job Title Years AcquaintedHow do you know this person? Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name First Last PhoneCompany Name Job Title Years AcquaintedHow do you know this person? Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name First Last PhoneCompany Name Job Title Years AcquaintedHow do you know this person? Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Applicant’s AgreementPlease read and check each box to indicate your understanding of each paragraph before submitting. In exchange for your extending me the opportunity of seeking employment with Jasper Rubber Products (hereafter referred to as the “Company”), I understand and agree that:Falsification*Any falsification or omission of fact made in my application for at-will employment or in connection with any background investigation may be sufficient grounds for rejection of my application, or, if discovered either after an offer of employment or after employment has commenced, for immediate dismissal. I have read and do acknowledge that I understand and agree to the above paragraph Consent to Contact Past Employers*I give permission to Jasper Rubber to contact all employers listed in my application (except those specifically excluded) for references. I further give permission to all current or previous employers and/or managers or supervisors to discuss with Jasper Rubber my personal and employment history, consent to the release of such information orally or in writing, and hereby release them from all liability and agree not to sue them for defamation or other claims based upon any Statements they make to any representative of Jasper Rubber. I further waive any rights I may have to receive a copy of any written Statement provided by any of my former employers to Jasper Rubber. I further agree to indemnify all past employers for any liability they may incur because of their reliance upon this release. I have read and do acknowledge that I understand and agree to the above paragraph Substance Screening Examination*Employment is contingent upon my satisfactory completion of the Company’s substance screening examination. This examination will include a drug test to detect the presence of non-prescribed or prohibited controlled substances in my system. I understand that collected test samples and results will be the property of the Company. Any doctor, hospital, or testing laboratory may conduct medical or drug tests, and I hereby give my consent to have all information released necessary for the Company to determine my abilities to perform job duties now or in the future. I have read and do acknowledge that I understand and agree to the above paragraph Consent to Conduct Background Investigation*As a condition of and in consideration for Jasper Rubber’s consideration of my application for, or continuation of my, at-will employment, I give permission to Jasper Rubber to investigate my personal and employment history. I understand that this background investigation will include, but not be limited to, verification of all information on this application, as well as interviews with past employers I further give permission to Jasper Rubber to conduct this investigation and to discuss the results of this investigation in connection with my application for employment. I have read and do acknowledge that I understand and agree to the above paragraph Consent to Contact Government Agencies*I give permission to any agent, attorney, or representative of Jasper Rubber to receive a copy of any information obtained in the file of any federal, State, or local court, governmental agency, law enforcement agency, or investigator concerning or relating to me. I further consent to the release of such information and waive any right under State law concerning notification of the request for a release of such information. In the event a State law does not provide for prospective employers to have access to information, I hereby delegate Jasper Rubber as my agent for receipt of information. I understand that the scope of this investigation will be limited to criminal and/or civil records that relate to my honesty, integrity and/or abilities and suitability for employment with Jasper Rubber. I have read and do acknowledge that I understand and agree to the above paragraph Cooperation with Investigation*I agree to fully cooperate in Jasper Rubber’s background investigation into my suitability for employment and further, if employed, to fully cooperate in any investigations, which arise during my employment, and to sign any waivers or releases that may be necessary to obtain access to relevant information. In the event that any former employer or federal, State, or local government agency will not release reference information or criminal history information directly to the employer, I agree to personally request such information and take such steps as may be necessary to furnish it to Jasper Rubber to the extent permitted by law. I have read and do acknowledge that I understand and agree to the above paragraph Employment “At Will"*If I am offered and accept employment with the Company, such employment may be terminated “at will” at any time by myself, or at any time by the Company, for any reason, and with or without notice, except as otherwise provided by law. If terminated, the Company is liable only for wages or Salary and other benefits earned by me as of the date of such separation. I agree to conform to the rules and regulations of the Company, and I understand that no interviewer, employee, officer or any other representative of the Company has any authority to enter into any agreement, oral or written, for employment for any specified period of time, or to make any agreement or contract contrary to this agreement. I have read and do acknowledge that I understand and agree to the above paragraph Equal Opportunity Employer*The Company is an Equal Opportunity Employer. The Company does not discriminate in any condition of employment based upon age, race, color, religion, sex, national origin, disability, military status or other legally protected status. No question on my employment application is used for a purpose of limiting or excluding any applicant’s consideration for employment on a basis prohibited by local, State, or federal law. I have read and do acknowledge that I understand and agree to the above paragraph
