Application for Employment  Victor, IA Division It is the company policy to comply with all applicable state and federal laws prohibiting discrimination in employment based on race, age, color, sex, religion, national origin, or other protected classification. * Indicates required fields.   Date  Name    Social Security #  Address                      Street                                                                City                              State                          Zip  Telephone Number      Are you over 18 years of age? Yes  No  Are you authorized to work in the U.S. on an unrestricted basis? Yes   No  How did you learn of this opening?   Have you previously worked (includes Temporary/Contract/Fulltime/Parttime)  at any of the Victor Plastics Divisions?  Yes No If yes, at which Divison did you work and what year? (please include name of Temporary Agency if appropriate)  Are there any hours, shifts or days you cannot or will not work?   Shift preferred               Part-time       Full-time  Are you willing to work overtime as required? Yes   No  Have you ever plead guilty to or been convicted of a crime other than a misdemeanor?     Yes    No (Conviction will not necessarily disqualify an applicant for employment.)  If yes, describe conditions:     Education   Name and Location of School   Year Graduated   Major   Diploma/Degree   High School             College/Univ.              College/Univ.             Other Training or Education   Position(s) Applying for: Desired Wage: Date Available if Hired? Any other relevant Training or Certifications?     May we contact your present employer for an employment reference? Yes No Start with your present or most recent job and list all prior employers within the past ten years. Victor Plastics considers the military as employment.  If additional space is needed, please write on the backside of this page.  Employer  Address  Telephone  Date Started                  Starting Salary $   Per  Starting position  Date Left                        Ending Salary $ Per  Position on leaving  Name of Supervisor  Title of Supervisor Description of Duties Reason for Leaving    Employer  Address  Telephone  Date Started Starting Salary $ Per   Starting position  Date Left  Ending Salary $ Per   Position on leaving  Name of Supervisor  Title of Supervisor Description of Duties: Reason for Leaving:    Employer  Address  Telephone  Date Started  Starting Salary $ Per   Starting position  Date Left  Ending Salary $ Per   Position on leaving  Name of Supervisor  Title of Supervisor Description of Duties: Reason for Leaving:    Employer  Address  Telephone  Date Started Starting Salary $ Per  Starting position  Date Left  Ending Salary $ Per  Position on leaving Description of Duties: Reason for Leaving:   BE SURE TO READ THIS STATEMENTS BEFORE SIGNING I certify that answers given are true and complete and contain no misrepresentations. Furthermore: I understand that false statements made on this application may eliminate me from further consideration for employment or will be grounds for dismissal. I authorize Victor Plastics, Inc., to conduct or participate in any investigation of my personal background, work history and police record as may be necessary to verify the information provided in my employment application and to determine my fitness to hold the position for which I have applied. I agree to provide a specific written release and/or waiver of confidentiality should it be necessary for a background check. I understand that if I am hired, I will be expected to comply with the requirements of the Immigration Reform and Control Act of 1986 by providing verification of identity and employment eligibility per provisions of the Act. I understand any offer of employment with all divisions of Victor Plastics, Inc., is contingent upon the results of a pre-employment physical and drug screen.  By signing below, I agree to the pre-employment physical and drug screen as arranged by Victor Plastics, Inc.           Signature of Applicant                                                               Date

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