Personal

Name

First Middle Last

Social Security Number

Phone*

Email

Address*

Street Address City 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:

Have you been convicted of a felony?*

Yes

No

Note: Conviction will not necessarily disqualify you from employment.

If yes, please explain

Are you eligible to work in the U.S.?*

Yes

No

Proof of citizenship or immigration status will be required upon employment.

Are 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*

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:

Work 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

Education

High School*

Address

Street Address City 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 State ZIP Code

Number of Years Completed

Degree Attained

Yes

No

Nature of Courses Taken or Degree Attained

College

Address

Street Address City State ZIP Code

Number of Years Completed

Degree Attained

Yes

No

Nature of Courses Taken or Degree Attained

Graduate School

Address

Street Address City State ZIP Code

Number of Years Completed

Degree Attained?

Yes

No

Nature of Courses Taken or Degree Attained

Skills and Experience

Summarize 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 Resume

Max. file size: 20 MB.

References

List 3 individuals who are best acquainted with your work performance and/or academic achievement.

Name

First Last

Phone

Company Name

Job Title

Years Acquainted

How do you know this person?

Address

Street Address City State ZIP Code

Name

First Last

Phone

Company Name

Job Title

Years Acquainted

How do you know this person?

Address

Street Address City State ZIP Code

Name

First Last

Phone

Company Name

Job Title

Years Acquainted

How do you know this person?

Address

Street Address City State ZIP Code

Applicant’s Agreement

Please 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.