Employment Application – Cummins

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Employment Application
Cummins Location:                                                      Today's Date:                     Reviewed By:                      Date available to start work:


Print name in full:   LAST                       FIRST                          MIDDLE                   Social Security No.:              Salary expected:


Present address:                                                                                         City:                             State & Zip Code:


Previous addresses over the past 10 years:                                                               Email address:                    Phone No. & Area Code:



Position applying for:                                                                                   Can you furnish proof of age?     Cell Phone No. & Area Code:


HAVE YOU EVER BEEN CONVICTED OF A CRIMINAL OFFENSE IN THE PAST SEVEN YEARS? ___ YES ___ NO.
EXPLAIN (USE THE BACK OF SHEET IF NECESSARY). YOUR ANSWER IS LOOKED UPON AS ONLY ONE OF THE FACTORS CONSIDERED IN THE EMPLOYMENT DECISION AND IS EVALUATED IN
TERMS OF THE NATURE, SEVERITY, AND THE DATE OF THE OFFENSE. LIST ONLY CONVICTIONS WHERE THERE HAS BEEN A DISPOSITION GIVEN BY THE COURT OR ANY OPEN / PENDING
CASES. CONVICTIONS FOR MARIJUANA POSSESSION UNDER 1 GRAM EXCEEDING 2 YEARS NEED NOT BE REPORTED.

Date(s) of Conviction(s) / Where?


List other names you have been known by over the past 10 years:                                          Have you previously been employed by an affiliate or us? If yes,
                                                                                                         who?

Do you have a current driver's medical certificate?:     ____ YES    ____ NO                             Drivers License Number & State:
Expiration Date:

This job may require a valid drivers license. List your license Class _____.   Does your license require a physical? _____.     License Expires:_______________.
List any endorsements on your license:

                                                                         EDUCATION DATA
              LEVEL                                    NAME & LOCATION (CITY/STATE)                              COURSE OR MAJOR                    YEAR GRADUATED

HIGH SCHOOL:                                                                                                 Graduated - list only

                                                                                                            Yes ____ or No ____
COLLEGE:

TRADE:

OTHER:

Are you legally permitted to work in this Country?        Yes ___     No ____                            Is DMV print out submitted;
 If no, why?                                                                                             (May be required)                    Yes ____      No ____
Do you have any job accomplishment of which you are particularly proud? Explain in detail.



List 2 Professional references by name & phone number:
    1.                                                                                     2.


Are you currently employed?         May we contact your present employer before hiring?                  May we contact you at your present employer?
   ___ yes           ___ no         ___ yes             ___ no                                             ___ yes ___ no ___ yes, but carefully.
Do you intend to submit a resume as part of your application? ____ Yes ____ No.
If yes, initial your acceptance of the terms and conditions of this application form being applied to the information contained in your resume. _____________.
The fact that you have filled out this application will be kept strictly confidential and will not in any way be brought to the attention of your present employer without
your permission. Please give an accurate, detailed and complete record of your employment. Make sure that you list the full name of the person to whom you reported
and the phone number for each employer. Begin with your present position (please go to next page).
                                                                                                                      1903-00-060411-Cummins Application Form with new logo.doc
                       PLEASE LIST ALL JOBS HELD FOR THE PAST TEN (10) YEARS. USE BACK OF SHEETS TO LIST ADDITIONAL INFORMATION.
MOST RECENT EMPLOYER:                                                                                    Supervisors name & title:

                                                                                                         May we contact this supervisor?  YES  NO
Street address:                                                                                          Phone number & area code:

City:                                                                     State:       Zip:              Your job title:


Your job title & description:                                                                                                             From (M/YR):
                                                                                                                                          To:
                                                                                                                                             -------------------------------
                                                                                                                                          Salary:
Reason for leaving:                                                                                      Describe one major job accomplishment:



EMPLOYER #2:                                                                                             Supervisors name & title:

                                                                                                         May we contact this supervisor?  YES  NO
Street address:                                                                                          Phone number & area code:

City:                                                                     State:       Zip:              Your job title:


Your job title & description:                                                                                                             From (M/YR):
                                                                                                                                          To:
                                                                                                                                              -------------------------------
                                                                                                                                          Salary:
Reason for leaving:                                                                                      Describe one major job accomplishment:



EMPLOYER #3:                                                                                             Supervisors name & title:

                                                                                                         May we contact this supervisor?  YES  NO
Street address:                                                                                          Phone number & area code:

City:                                                                     State:       Zip:              Your job title:


Your job title & description:                                                                                                             From (M/YR):
                                                                                                                                          To:
                                                                                                                                              -------------------------------
                                                                                                                                          Salary:
Reason for leaving:                                                                                      Describe one major job accomplishment:



PERIODS OF UNEMPLOYMENT: (describe each period of unemployment in excess of 30 days for the past 10 years)
 From          To            Reason
______________________________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY: THEY CONSTITUTE THE CONDITIONS UNDER WHICH YOU MAY BE EMPLOYED.
   The information that I have provided herein is accurate to the best of my knowledge. I hereby authorize the Company and/or its agents to investigate my background
and to verify any and all information of concern to my records, whether such information if favorable or unfavorable to me. I understand that any material
misrepresentation or deliberate omission of a fact in my application may be justification for refusal of employment, or if employed, termination from the Company. I
acknowledge that any copy of this document carries the full force of the original document for legal purposes. I do hereby agree to forever release and discharge the
Company, their agents, and their associates to the full extent permitted by law from any claims, damages, losses, liabilities, costs, and expenses, or any other charge or
complaint filed with any agency arising from the retrieving and reporting of information. By checking here _____ I do request a copy of my consumer report if that
report is made part of this investigation of me.
   I hereby acknowledge than any employment relationship with Cummins West, Inc. is of an "at will" nature, which means that an Employee may resign at any time and
Cummins West, Inc. may discharge an Employee at any time with or without cause, and with or without notice. This "at will" employment rela tionship may not be changed
by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of Cummins West, Inc. For an Employee
covered by a collective Bargaining Agreement, applicable discharge provisions of that agreement shall govern.
   In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand also, that I
am required to abide by all rules and regulations of Cummins West, Inc.
   I agree and understand that any offer of employment will be conditional on my successful completion of a pre-employment physical examination and drug screening
test. Also, if hired, I understand that as part of company policy, I agree to a drug screen test if I required medical attention from a physician due to a work related
injury.

Date: _____________________                              Applicant's Signature: _____________________________________________________
                                                                                                                   1903-00-060411-Cummins Application Form with new logo.doc
                                                      SKILLS
(1) To be completed by Service/Technical Applicants

                                       TRUCK AND ENGINE EQUIPMENT
                Area                Formal      Years of                 Area                        Formal         Years of
                                   Training    Experience                                           Training       Experience
                                   (Check)                                                          (Check)
Drive Line Components                                       Electrical Repair
Diesel Engine Tune-up & Rebuild                             Frame and Wheel Alignment
Gas Engine Tune-Up and Rebuild                              Brakes
Tire Service                                                Cooling System
Trailer Repair                                              Inspections
Air Conditioning                                            General Car Repair
                                               SHOP EQUIPMENT
                Area                Formal      Years of                 Area                        Formal         Years of
                                   Training    Experience                                           Training       Experience
                                   (Check)                                                          (Check)
Electrical Diagnostic Equipment                             Air Conditioning
Sheet Metal Equipment                                       Wheel/Tire Balance Machine
Frame & Axle Straightening                                  Engine Dynamometer
Equip.
Engine Rebuilding Equipment                                 Chassis Dynamometer
Diesel Injection Equipment                                  Engine Analyzer
Electric Welder                                             Inspections
Oxyacetylene Welder                                         Noise Measuring Equipment
Paint Spray Gun                                             Smoke Measuring Equipment

(2) To be completed for Office/Administrative & Supervisory Positions:

                                              ADMIN/OFFICE SKILLS
                Area                Formal      Years of                 Area                        Formal         Years of
                                   Training    Experience                                           Training       Experience
                                   (Check)                                                          (Check)
Computer Data Entry                                         Computer Programs:
Typing (WPM ________)                                        MS Word
Accounts Payable & Receivable                                MS Excel
Supervisory Experience                                       MS Access
Office Equipment:                                            MS Powerpoint
Computer                                                    Quickbooks
Type of computer:
________________________                                    Version: _________

Fax Machine                                                 Email
Photocopy Machine                                           Internet Use
Other Skills: (please list)                                 Other Computer Programs: (please list)




                                                                                 1903-00-080903-Cummins Application Form.doc
    THIS SECTION TO BE COMPLETED BY CUMMINS WEST, INC. ONLY
                                  EMPLOYMENT CHECK-OFF LIST
REFERRED BY/AGENCY _____________________________________________________________________

POSITION APPLYING FOR: __________________________________ BRANCH _______________________

RESUME ATTACHED: ________YES            ________ NO

BACKGROUND CHECK FAXED ON: ___/___/___ TIME: _______

BACKGROUND CHECK RETURNED ON: ___/___/___

PHYSICAL COMPLETED ON: ___/___/___             DRUG TEST COMPLETED: ___/___/___

INTERVIEW DATE: ___/___/___                    INTERVIEW TIME: ________

INTERVIEW BY: ___________________________________________________________________________

HIRE APPROVAL(S): _______________________________________________________________________

START DATE: ___/___/___       SALARY: ___________

                                                COMMENTS
________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________
                                                             1903-00-060411-Cummins Application Form with new logo.doc
                                                              Affirmative Action Self ID Survey
Applicants and employees are treated without regard to race, color, religion, sexual orientation, gender, national origin, citizenship status (unless
required by a government contract), age, marital or veteran status, physical or mental disability, or any other legally protected status during every
aspect of the employment process.
As employers and government contractors, we comply with government regulations and affirmative action responsibilities. Solely to help us comply
with affirmative action record keeping, reporting and other legal requirements, please complete the survey below. This information will not be used
for hiring, placement, or other decisions related to the terms and conditions of employment. This document will be kept in a confidential file, separate
from applicant and personnel files. When reported, data will not identify any specific individual.
                                                     YOUR COOPERATION IS VOLUNTARY
                     INCLUSION OR EXCLUSION OF ANY DATA WILL NOT AFFECT ANY EMPLOYMENT DECISION
Please complete the following information. Please print.
 Last Name:                                                                 First Name:
 Date:                                                                      Job Title/Req Number:

Gender

         Male                  Female

Ethnicity - Are you Hispanic or Latino? (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin,
regardless of race.)

         Yes                   No

Race - If you are not Hispanic or Latino, please select the appropriate race category.

         White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or North
         Africa.

         Black or African American (Not Hispanic or Latino)  A person having origins in any of the Black racial groups of Africa.



         Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the original peoples of
         Hawaii, Guam, Samoa, or other Pacific Islands.


         Asian (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the
         Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands,
         Thailand, and Vietnam.

         American Indian or Alaska Native (Not Hispanic or Latino) - A person having origins in any of the original peoples of North and
         South America (including Central America), and who maintains tribal affiliation or community attachment.



         Two or More Races (Not Hispanic or Latino) - persons who identify with more than one of the above five races.




          I respectfully decline completing the information being requested above.             ________ initials
                                                          EEO/AA/MFDV Employer




                                                                                                   1903-00-060411-Cummins Application Form with new logo.doc
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