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E M P L O Y M E N T A P P L I C A T I O N

INDUSTRIAL AUTOMATION CONSULTING, INC.
P.O. BOX 870
THREE FORKS, MT 59752

An Equal Opportunity Employer

Please read the following before filling out this form.
Industrial Automation Consulting, Inc. (IAC) is an equal opportunity employer and does not discriminate in hiring or employment on the basis of age, race, creed, color, religion, sex, national origin, marital status, or disability. No question on this application is intended to secure information to be used for such discrimination.

This application will be given every consideration, but its receipt does not imply that the applicant will be employed.

Please complete all questions. This application will not be considered if questions are left unanswered.

Date	Position Applying For	Salary Desired

Last Name	First Name	Middle Initial	Social Security Number
			- -

General Information

Home Address	(No. & Street)	(City)	(State & Zip)

Telephone Number	E-mail Address	Are you legally eligible to work in the U.S.(verification will be required upon hire)?(Check one)
( ) -		Yes No

Have you every been convicted of a felony? (Check one) Yes No
If yes, explain date, location, and offense. A yes does not automatically disqualify you from employment. All circumstances will be considered.

Education

High School (Name):
Grades Completed (Choose one):	9 10 11 12	City/State:
Business/Trade School (Name):
Major:	#Years Completed:	City/State:
College or University (Name):
Degree:	#Years Completed:	City/State:

Employment

List the last 5 positions you have held starting with your most current employment.

From Mo/Yr

To Mo/Yr

Employer

Positions Held/Duties

Name
Address
City/State
Supervisor
Phone No.	( ) -

Current/last pay rate	Reasons for leaving

From Mo/Yr

To Mo/Yr

Employer

Positions Held/Duties

Name
Address
City/State
Supervisor
Phone No.	( ) -

Current/last pay rate	Reasons for leaving

From Mo/Yr

To Mo/Yr

Employer

Positions Held/Duties

Name
Address
City/State
Supervisor
Phone No.	( ) -

Current/last pay rate	Reasons for leaving

From Mo/Yr

To Mo/Yr

Employer

Positions Held/Duties

Name
Address
City/State
Supervisor
Phone No.	( ) -

Current/last pay rate	Reasons for leaving

From Mo/Yr

To Mo/Yr

Employer

Positions Held/Duties

Name
Address
City/State
Supervisor
Phone No.	( ) -

Current/last pay rate	Reasons for leaving

If there are any periods unaccounted for, please explain:

Personal References

Give the name of 3 personal references who are not relatives or previous employers.

Name	Address(City/State)	Occupation	Phone No.
			( ) -
			( ) -
			( ) -
			( ) -

Skills

Indicate experience and/or training you have received that would qualify you for the position for which you are applying by completing the appropriate space.

COMPUTER SOFTWARE

Software Name and Version (e.g. Microsoft Access 7.0)	No. Years Experience	Describe Skill Level/Experience (e.g., basic use, intermediate, application development, problem diagnosis/debugging, customer support, etc.)
Word Processing


Spreadsheet



Database




Operating System



Other (e.g., desktop publishing)

Describe other special skills or experience that you have not noted in other parts of this application but which you feel would help you in this position.

Please list any certifications, licenses, etc. that you posses which are related to the position for which you are applying.

APPLICANT CERTIFICATION

READ CAREFULLY BEFORE SUBMITTING

I certify that the information in this application is true and complete. Any false statements, concealments or omissions are grounds for refusal for hire or immediate dismissal if hired.

I authorize schools, former employers, former supervisors and co-workers to provide any and all information pertinent to my being considered for employment and hereby release those providing such information from any liability for doing so.

I understand that employment, if offered, is contingent upon my providing additional information for employee record purposes and also upon my providing proof of identity and employment eligibility and completing a Form I-9. I understand that if I am hired, the length of my employment is not guaranteed. Recognizing that I will be free to voluntarily terminate my employment at any time, with or without cause, I acknowledge that my employment can be modified or terminated with or without cause and with or without notice during the probationary period, and at any time for cause and that, if employed, employment does not constitute a contract of employment between myself and Industrial Automation Consulting, Inc. (IAC). I understand that no manager or representative of IAC, other than the President, has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, either prior to employment or after I have become employed. I will abide by and conform to all IAC policies, rules, and procedures as may be in effect from time to time.

I acknowledge that I have read the above, understand its content and meaning, and agree to all of it's provisions.

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