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Application - KPA

Klöckner Pentaplast of America, Inc.

540.832.3600 • P.O. Box 500
fax 540.832.5656 • Gordonsville, VA 22942

Klöckner Pentaplast of America, Inc., is an Equal Opportunity Employer
which makes employment decisions without regard to race, color, sex, religion,
national origin, age, handicap, disability or marital status.

Klöckner Pentaplast of America, Inc., is a Drug-Free Workplace.

You may not submit a resume without submitting an application.

Red fields marked with an " * " must be completed for kpA to accept this application.

*Full Name:
*Position for which applying:
Position must be entered for application to be considered. Only those open positions
posted on the web site can be used.
*Date:
*Email Address:

PERSONAL INFORMATION
* Last Name: Cell Phone:
* First Name: * Home Phone:
Middle Name: Business Phone:
Street Address: Social Security #:
City: * Pay Expected:
State:
Zip:
Have you ever applied for employment with us?
yes   no
if yes, month/year and location:
* Are you at least 18 years old?   type yes or no
* On occasion, overtime work is required.
Is there any reason you would not be available for over-time work?
  type yes or no
  if yes, please explain:
* Are you available to work 12-hour shifts?  type yes or no
* Are you available to rotate from
day to night shift?
 type yes or no
* Are you available to work weekends
and holidays?
 type yes or no
Have you ever been convicted of a felony?
yes   no
if yes, please explain:
* Are you authorized to work in the U.S.?  type yes or no
If you are not a U.S. citizen, do you have permission to live and work in the U.S.? yes   no

EDUCATION  
May or may not be considered depending upon the job for which you are applying
School Name &
Location
Course
of Study
# of Years Completed Did you graduate? Degree or
Diploma?
Graduate
School
College
Business/
Trade/
Technical
High
School

EMPLOYMENT HISTORY
Please give accurate, full-time and part-time employment record.
Start with your present or most recent employer.
1  
Company Name: Telephone:
Address: Employed from:
(month/year to month/year)
Name of Supervisor: Start rate of pay:
Job Title: End rate of pay:
Describe your work:
Reason for leaving:
2  
Company Name: Telephone:
Address: Employed from:
(month/year to month/year)
Name of Supervisor: Start rate of pay:
Job Title: End rate of pay:
Describe your work:
Reason for leaving:
3  
Company Name: Telephone:
Address: Employed from:
(month/year to month/year)
Name of Supervisor: Start rate of pay:
Job Title: End rate of pay:
Describe your work:
Reason for leaving:
4  
Company Name: Telephone:
Address: Employed from:
(month/year to month/year)
Name of Supervisor: Start rate of pay:
Job Title: End rate of pay:
Describe your work:
Reason for leaving:

Please explain any gaps in your employment history:
Have you ever been discharged or forced to resign? Explain:
We may contact the employers listed above unless you request otherwise.
Do Not Contact: employer number(s) Reason:

* Who referred you for a position here?:
List any friends or relatives currently employed here:
Please list three people not related to you, who can provide professional or character references:
  Name Address Phone
1)
2)
3)
Describe any training relevant to the position for which you are applying:
List any job skills you have acquired, i.e. fork truck, production machinery, keyboarding, computer software, maintenance, etc.
Did you serve in the U.S. Armed Forces or National Guard?
yes   no
if yes, what branch and when?
Have you signed any non-compete agreements or any other agreements with any other employer that would restrict you from working with this company?
yes   no
if yes, please explain:

ACKNOWLEDGEMENT OF APPLICANT:
I certify that the answers given herein 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 will disqualify me from further consideration for employment. I further understand that, if employed, any misrepresentations or omissions of facts in any application document will be cause for my dismissal at any time without prior notice.

I understand that, if employed, my employment with Klöckner Pentaplast is not for a specific term and may not be terminated by me or the Company without notice or cause at any time. I further understand that no oral promise, Employer policy, custom, business practice or other procedure (including the Employer's Personnel Handbook or any other personnel manuals) constitute an employment contract or modification of the at-will employment relationship between me and the Employer.

I understand that any employment offer is contingent upon successfully completing a pre-employment medical examination, which includes a drug test. I authorize the Company to investigate my background, including, but not limited to criminal history, previous employment, references, driver's license, education verification, and credit history.

I acknowledge that this application will remain active for 60 days from this date. If I have not heard from the Company at the conclusion of this 60-day period, it is my responsibility to complete a new application if I still wish to be considered for employment by the Company.
* Type Your Name Here As Signature:
* Date

Pursuant to federal regulations, we collect responses to the questions below for record keeping purposes. This information will NOT be kept with your application for employment. Federal law prohibits unlawful discrimination on the basis of race, color, gender, age, national origin, religion, or disability.
Check the box for the racial group with which you identify:
White (includes Arabian)
Black (includes Jamaican, Bahamian, and other Caribbean of African but not Hispanic or Arabian descent).
Hispanic (includes persons of Mexican, Puerto Rican, Central or South American, or other Spanish origin or culture)
Asian and Asian American (includes Pakistanis, Indians and Pacific Islanders)
American Indians (includes Alaskans)
Check the appropriate box:
Female
Male
For the purposes of compliance with Section 2.1-112 of the Code of Virginia, have you ever served in the Armed Forces of the United States during the following dates (check the appropriate dates):
World War I - 4/16/17 - 2/1/20
World War II - 12/7/41 - 12/31/46
Korean Conflict - 6/27/50 - 1/31/55
Vietnam Conflict - 8/5/64 - 3/7/75
None of the dates shown, but I did serve in the military.
I have not served in the military.
How did you learn about the job opportunities at Klöckner?
Newspaper (please specify:)
Radio
Internet
Television
VEC
Recruiter
Other (please specify:)
Type Your Name Here As Signature:
Date

RESUME
If you choose to do so,
you may attach your resume here.

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