Mosack Group Employment Application 11210 Allen Station Dr, Mint Hill, NC 28227 Name * First Last Street Address * City * State * Zip Code * Phone Number * Email Address Date Available To Work Desired Position Desired Salary Per Hour (USD $) Are you at least 18 years of age? * Yes No What shift do you prefer to work? 6:00 AM - 2:30 PM 9:00 AM - 5:30 PM 10:00 PM - 6:30 AM Are you a United States citizen? * Yes No If no, are you authorized to work in the U.S? Yes No Have you ever applied to or worked for Conbraco Industries, Inc. or the Mosack Group? Yes No If yes, when? Do you have any friends or family who work for the Mosack Group? If so, list their name(s). Any additional business or jobs engaged in? Explain. Have you ever been convicted of, or pleaded guilty to, a crime other than a minor traffic offense? Yes No If yes, please explain. Education Please list any high schools, colleges, training programs, or other institutions of higher learning you attended. High School Name and Location Years Attended Did you graduate? Yes No College Name and Location Years Attended If you graduated, please list major and degree received. Other education or training Are you currently enrolled in additional studies? Yes No If so, list the school, location and courses/programs of study. Skills Please list all skills and accomplishments you have. List office equipment you can operate List warehouse equipment you can operate List computer skills you have (hardware and software) List any additional training, skills, languages spoken, interests you have you want us to know References Please list up to three professional references. Name and Relationship To You Company and Location Phone Number Name and Relationship To You Company and Location Phone Number Name and Relationship To You Company and Location Phone Number Previous Employment Please begin with your current or most recent employer. Company Address Phone Job Title Job Responsibilities Supervisor Ending Salary Reason for leaving May we contact your previous supervisor? Yes No Company Address Phone Job Title Job Responsibilities Supervisor Ending Salary Reason for leaving May we contact your previous supervisor? Yes No Company Address Phone Job Title Job Responsibilities Supervisor Ending Salary Reason for leaving May we contact your previous supervisor? Yes No Military Service Please fill out if you have served in the military. Branch Dates Served Type of Discharge Rank at Discharge If other than honorably discharged, please explain. Disclaimer Please read carefully before agreeing. Disclaimer #1 * I Agree I certify that the information in this application is correct to the best of my knowledge. Further, I understand that falsification of this information or any misstatement or omission of any fact of this information will result in rejection for employment or immediate dismissal if employed. Disclaimer #2 * I Agree I authorize any of the persons or organizations referenced in this application to give The Mosack Group, Inc. any and all information concerning my previous employment, education, or any other information they might have, personal or otherwise, with regard to any of the subjects covered by this application. I release all such parties from liability for any damage that may result from furnishing such information to The Mosack Group, Inc. I release The Mosack Group and its representatives from liability for seeking such information. I also authorize all law enforcement agencies to release to The Mosack Group, Inc. information pertaining to myself. I understand that an offer of employment is contingent upon the satisfactory completion of a background check, drug screening test, and physical examination. Disclaimer #3 * I Agree I agree to abide by the rules and regulations of the company and acknowledge that the company may change, interpret, withdraw or add to these rules and regulations at any time with or without prior notice. Disclaimer #4 * I Agree If employed, I understand that my employment is at-will, which means that it can be terminated, without cause, with or without prior notice, at any time, by either the company or me. Neither this application, nor any handbook, directive, employee manual, company policies and procedures or statement by any employee or member of management shall alter the above described at-will status of my employment with The Mosack Group, Inc. I understand that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to assure continuation of any benefits or terms and conditions of employment, or make any agreement contrary to the foregoing, except as confirmed in writing by a company officer. Disclaimer #5 * I Agree In the event I am provided with a written offer of employment with The Mosack Group, Inc., I hereby give my consent to any doctor as well as his/her employee or agent(s), together with any clinic, hospital or laboratory, to perform appropriate tests or examinations on my body and its fluid samples (i.e. urinalysis, blood chemistry, etc.) for drugs and/or alcohol as part of a pre-employment physical examination. In the event I accept employment with The Mosack Group, Inc., I understand that I will be subject to the company’s policy statement in effect at the time and as amended pertaining to drugs and alcohol. Disclaimer #6 * I Agree I understand that by using this form, the company is not indicating that there are any position openings; nor does use of this form in any way obligate the company to my employment. Name * First Last Date / Time * Consent for Drug Screen Testing I agree and consent to undergo tests and/or urinalysis as a prerequisite to my employment. Additionally, as a condition of my employment, I agree that at such time or times during my employment, as The Mosack Group, Inc. shall require, I will consent to and undergo blood tests and/or urinalysis. I further agree that at the time of such examination, I will execute all forms of consent and release of liability as are usually and reasonably attendant to such examinations. Finally, I agree that the results of any such examinations shall be made available to The Mosack Group, Inc., its employees or agents. THE UNDERSIGNED FURTHER STATES THAT HE OR SHE READ THE FOREGOING CONSENT FORM AND KNOWS THE CONTENTS THEREOF AND SIGNS THE SAME OF HIS OR HER OWN FREE WILL. Name * First Last Date / Time * If you wish to email a resume, please send a .pdf, .doc, or .docx file type to arthur@mosackgroup.com.
