Employment Application

Step 1 of 8

Position Applied For*
Shift Preferred*
- First
- Second
- Other
Date Available to Start Work
Personal Data
Name*
First Middle Last
Application Date*
MM slash DD slash YYYY
Address*
Street Address City State ZIP Code
Primary Phone*
Secondary Phone
Email Address*
Referred by
- Our Advertisement
- Friend or Relative

References
List Three Business Related Individuals
Reference 1
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number
Occupation
Reference 2
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number
Occupation
Reference 3
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Occupation

Other Job-Related Experience
Some people gain job-related experience in positions other than as an employee. For instance, an accountant may gain experience as a treasurer of a civic or school organization, or a manager may gain experience while working on civic projects, or in school organizations, or in PTA activities. Please list and describe any paid or unpaid activities, honors, experience, or training that might aid you in performing the job(s) for which you have applied, and have not been listed previously in this application. (You may omit any activities, honors, memberships or other items that tend to identify your race, sex, national origin, age, disability or other personal traits that you prefer not to disclose.)
Please add any additional information (except that which identifies your race, color, religion, sex, national origin, age, disability, genetic information, citizenship, status as a Vietnam-era, special disabled veteran, or other veteran who served on active duty during a war, campaign, or expedition, for which a campaign badge has been authorized, in accordance with applicable federal laws) that you think may be relevant to a decision to hire you.
Please Read Carefully and Initial Each Paragraph Before Signing
Initial After Reading*
By my signature and initials, I promise that the information provided in this employment application (and accompanying resume, if any) is true and complete, and I understand that any false information or significant omissions may disqualify me from further consideration for employment, and may be justification for my dismissal from employment by Catalytic Combustion Corporation if discovered at a later date. I agree to immediately notify Catalytic Combustion Corporation if I should be convicted of a felony, or any crime involving dishonesty or a breach of trust while my job application is pending, or during my period of employment, if hired.
Initial After Reading*
I authorize any person, school, current employer (except as previously noted), past employer(s), government or investigative agencies, and other organizations that may be named in this application form (and accompanying resume, if any) to provide the company with relevant information and opinion that may be useful to Catalytic Combustion Corporation in making a hiring decision, and I release such persons and organizations from any legal liability in making such statements.
Initial After Reading*
I understand that, if hired, I may not hold other employment, nor engage in consulting, sales, investments or other activities that may create a conflict of interest with Catalytic Combustion Corporation.
Initial After Reading*
I understand that this application does not, by itself, create a contract of employment. I understand and agree that, if hired, my employment is for no definite period of time, and may, regardless of the date of payment of my wages or salary, be terminated at any time. I understand that only the President of Catalytic Combustion Corporation is authorized to change any of the terms of employment and that any changes must be specific and in writing.
Name
First Last
Date
MM slash DD slash YYYY
Upload Resume
Accepted file types: pdf, doc, docx, jpg, jpeg.
Max. file size: 64 MB.

Voluntary Self-Identification of Disability
Why are you being asked to complete this form?
We are a federal contractor or subcontractor required by law to provide equal employment opportunity to qualified people with disabilities. We are also required to measure our progress toward having at least 7% of our workforce will be individuals with disabilities. To do this, we must ask applicants and employees if they have a disability or have ever had a disability. Because a person may become disabled at any time, we ask all of our employees to update their information at least every five years. Identifying yourself as an individual with a disability is voluntary, and we hope that you will choose to do so. Your answer will be maintained confidentially and not be seen by selecting officials or anyone else involved in making personnel decisions. Completing the form will not negatively impact you in any way, regardless of whether you have self-identified in the past. For more information about his form or the equal employment obligations of federal contractors under Section 503 of the Rehabilitation Act, visit the U.S. Department of Labor's Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.
How do I know if I have a disability?
You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition. Disabilities include, but are not limited to:
- Autism
- Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, or HIV/AIDS
- Blind or low vision
- Cancer
- Cardiovascular or heart disease
- Celiac disease
- Cerebral palsy
- Deaf or hard of hearing
- Depression or anxiety
- Diabetes
- Epilepsy
- Gastrointestinal disorders, for example, Crohn's disease, or irritable bowel syndrome
- Intellectual disability
- Missing limbs or partially missing limbs
- Nervous system condition for example, migraine headaches, Parkinson's Disease, or Multiple Sclerosis (MS)
- Psychiatric condition, for example, bipolar disorder, schizophrenia, PTSD, or major depression
Please check one of the boxes below
- YES, I HAVE A DISABILITY (or previously had a disability)
- NO, I DON’T HAVE A DISABILITY
- I DON’T WISH TO ANSWER
Name
First Last
Date
MM slash DD slash YYYY
Reasonable Accommodation Notice
Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.
Do you require a reasonable accommodation to apply for a job or to perform your job?
i Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp. PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.

Step 1 of 8

Personal Data

General Information

Education Data

High School

Technical, Vocational, Business or Military Training

College or University

Graduate School

Professional Seminars

Employment History

Present & Former Employers

Employment 1

Employment 2

Employment 3

Employment 4

Employment 5

Employment 6

References

Reference 1

Reference 2

Reference 3

Other Job-Related Experience

Please Read Carefully and Initial Each Paragraph Before Signing

Invitation to Applicants to Self-Identify for Affirmative Action Purposes

Affirmative Action Related Data

Protected Veteran Categories:

Voluntary Self-Identification of Disability

Why are you being asked to complete this form?

How do I know if I have a disability?

Reasonable Accommodation Notice

Catalytic Combustion Corporation

Memberships / Certifications

Company

Products

Industries

Time Period(s)	Reason(s) for Unemployment