EMPLOYMENT APPLICATION
Drug-Free Work Environment

It is Boomerang Rubber’s policy to provide equal employment  opportunity with regard to all terms and conditions ofemployment. Boomerang Rubber complies with federal and state laws prohibiting discrimination on the basis ofrace, color, religion, creed, national origin, disability, veteran status, military status, age, genetic  informationand/or other protected characteristics.

Employment requires a pre-employment drug screen test.
Applicant First Name*
Applicant Last Name*
Last four digits of Social Security Number
Mailing Address
Phone
City
State/Providence
ZipCode
Email Address*
Birth Month and Day (not year)
What is your preferred shift?
1st
2nd
3rd
Please check position(s) of interest:
Processing-Mill
Press Room
Shipping Associate
Processing - STAT
Finishing - Packaging
Maintenance
PIT (Forklift)
Tool and Die
Office - Clerical
Professional
Please check the best response for each question.

Have you been previously employed by Boomerang Rubber either directly or thorugh a staffing agency?

Do you have the legal right to be employed in the U.S.?

Are you at least 18 years of age?

Do you have reliable transportation to and from work?

Do you have a valid driver’s license?
How did you learn about Boomerang Rubber?
Walk-In
Newspaper
Job Fair
Date
Staffing Agency
Agency Name
Friend or Relative
First Name
Last Name
EDUCATION
High School
College
List Software you have used:
List Manufacturing Work Experience
List Leadership Roles you have held:
Provide at least a 4-year employment history.
List the most recent employment first.
Employer 1 Name, City and State
Business Phone
Dates
Position 1
Final Wage
Employer 2 Name, City and State
Business Phone 2
Dates 2
Position 2
Final Wage 2
Employer 3 Name, City and State
Business Phone 3
Dates 3
Position 3
Final Wage 3
Describe a time when you lacked ability or knowledge to complete a work assignment. What did you do?
Describe a workplace policy that you did not like. How did you deal with it?
Explain how your knowledge, skills, education can be applied in a work environment.
Describe a time when you learned something by reading.
Describe a time when you learned something by doing.
Describe your ideal job.

I certify that all information submitted by me on this application is true and complete. I understand that if any false information,omissions, or misrepresentations are discovered, my application may be rejected; if I am employed at time of discovery, my employment may be terminated.


In consideration for employment, I agree to abide by the company’s policies, procedures and to adhere to safe work practices. I agree that my employment and compensation can be terminated, with or without cause and with or withoutnotice, at any time, at either the company’s option or mine (at-will employment). I understand that the termsand conditions of my employment may be changed, with or without cause, and with or without notice, at any time by the com-pany. (initial) I understand that no company representative, other than its General Manager, and then only when inwriting and signed by the General Manager, has any authority to enter into any agreement for employment for any specific pe-riod of time, or to make any agreement contrary to the foregoing.

E-Signature*