Thank You! Online Job Application Pre-Employment Questionnaire - All application sections are required fields. Richland Glass is an Equal Opportunity Employer. Personal InformationFirst Name* Middle Name Last Name* Present Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Permanent Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell PhoneHome PhonePrimary / Preferred Phone* Cell Phone Home Phone Email* Enter Email Confirm Email Are you 18 years or older?* Yes No Are you prevented from lawfully becoming employed in this country because of visa or immigration status?* Yes No Employment DesiredPosition*PackerMachine OperatorOtherAdministrativePosition if not listed above* Date you can start*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Salary Desired* Are you employed now?* Yes No If so, may we inquire of your present employer?* Yes No Have you ever applied to this company before?* Yes No If so, Where? When? Referred By Former EmployersList Below the Last Three Employers, Starting with the last one first.Employer InfoClick the + at the end of the row to add another row.Start DateEnd DateEmployer Name & AddressPositionReason for Leaving Which of these jobs did you like best? What did you like most about this job?EducationHiddenGrammar School*NameLocationGraduated?Subjects StudiedHigh SchoolNameLocationGraduated?Subjects StudiedCollegeNameLocationGraduated?Subjects StudiedTrade, Business or Correspondence SchoolClick the + at the end of the row to add another row.NameLocationYears AttendedGraduated?Subjects StudiedGeneralSubjects of Special Study or Research WorkSpecial SkillsActivities: (Civic, Athletic, Etc. - NOTE: exclude Organizations the name of which indicates the race, creed, sex, age, marital status, color or nation of origin of its members)U. S. Military or Naval ServiceRank Present Membership in National Guard or Reserves ReferencesGive the names of three persons not related to you, whom you have known at least one year. Click the + at the end of the row to add another row.#1*NameAddressBusinessYears Acquainted HiddenMaryland and Massachusetts InformationThe following applies in: Maryland & Massachusetts. It is unlawful in these states to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.HiddenSelect your StateI do not live in Maryland or MassachusettsMarylandMassachusettsHiddenAcknowledgement* By checking this box, you acknowledge the above statement. Please check here if you filled in a state above. HiddenIn case of Emergency, notifyHiddenName HiddenAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code HiddenWork PhoneHiddenHome/Cell PhonePLEASE READ CAREFULLYPLEASE READ CAREFULLY: "I certify that all the information submitted by me on this application is true and complete, and I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected and, if I am employed, my employment may be terminated at any time. In consideration of my employment, I agree to conform to the company's rules and regulations, and I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company's option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice, at any time by the company. I understand that no company representative, other than its president, and then only when in writing and signed by the president, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing."Attestation* I have read and understand the statement above. Today's Date* MM slash DD slash YYYY This form has been designed to strictly comply with State and Federal fair employment practice laws prohibiting employment discrimination.