Application

PERSONAL INFORMATION

Last Name*
First Name*
Middle Name
Email*
Phone*
Referred By
Present Address
Permanent Address (if different from present address)

EMPLOYMENT DESIRED

Position*
Date You Can Start
Expected Rate of Pay
Are You Employed Now?

EDUCATION AND SKILLS

Describe Course of Study
Describe any specialized training, apprenticeship, skills or extra-curricular activities that are relevant to the job for which you are applying
Describe any honors, scholarships, appointments or awards you have received
State any additional information you feel may be helpful to us in considering your application

DRIVER'S LICENSE INFORMATION:

State
Number
Expiration Date
Restrictions or Suspensions (respond fully if driving is required by the job for which you are applying)

GENERAL INFORMATION:

FORMER EMPLOYERS:

Start with your present or last job. Include any job-related military service assignments and volunteer activities.

REFERENCES

List three non-employment references who are not related to you and have known you for at least one year.

IN CASE OF EMERGENCY NOTIFY:

Name
Relation to You
Address
Telephone Number

I UNDERSTAND AND ACKNOWLEDGE THE FOLLOWING:

1. I understand that I am entitled to copies of any public records obtained directly by the Company in connection with my application for employment.

   Check one: I waiveI do not waive my right to receive copies of public records obtained directly by the Company.

2. If I am offered employment, I will, as a condition of employment, be required to submit proof of my identity and legal right to work in the U.S.

3. I understand that, if I am employed, any false statement, misrepresentation, or omission of facts on this application or on any supporting documents, regardless of when discovered to be false or omitted, may result in my immediate dismissal.

4. I understand that I will be required to possess a current and valid California driver's license if my job requires me to drive in the course of my work.

5. I agree that, if I am offered a position, it will be offered on condition that my employment shall be at will and for no definite period, and that my employment may be terminated at any time with or without cause and with or without prior notice. I understand that, except for the President of the Valley Glass & Mirror, no supervisor or manager may alter or amend the above conditions. Only the President of the Company has authority to enter into any agreement for employment for any specified period of time or to make any agreement contrary to the foregoing.

6. I understand and agree that, if I am offered a position, it will be a conditional offer based on my successful passing of both a drug and alcohol screen and job related medical examination.

7. I understand and agree that as a condition of my employment I may be required to undergo a medical examination.

8. I understand and agree that as a condition of my employment, I may be required to undergo drug testing, and any other testing to the extent permitted by applicable laws.

9. I agree that I will settle any and all previously unasserted claims, disputes, or controversies arising out of or relating to my employment, my application or candidacy for employment, and/or cessation of employment with Valley Glass & Mirror, exclusively by final and binding arbitration before a neutral Arbitrator (pursuant to the Company's Alternative Dispute Resolution Policy). By way of example only, such claims include claims under federal, state, and local statutory law, such as the Fair Employment and Housing Act, Age Discrimination in Employment Act, Title VII of the Civil Rights Act of 1964, as amended, including the amendments of the Civil Rights Act of 1991, the Americans With Disabilities Act, the law of contract and the law of tort.

10. If I am offered employment, I will, as a condition of employment furnish proof that I am over 18 years of age.

11. I agree that, if I am offered employment, I will be required to conform to the rules and regulations of the Company.

12. I authorize investigation of all statements contained in this application and any supporting documents. I authorize the Company to secure information about my experience from former employers, educational institutions, govermnent agencies, or any references I have provided, and for those parties to provide information concerning my experience and I hereby release all parties from any liability arising from such investigation.

13. I understand that no supervisor or manager may alter or amend the conditions set forth in paragraphs one (1) through twelve (12) above. I understand that the foregoing conditions can only be altered or amended by a written agreement signed by Mr. Michael Hageman of Valley Glass & Mirror.

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