Electronic Manufacturing Services Group, Inc.

WHERE SERVICE COMES FIRST... ESTABLISHED 1995

Page 1 of 7

Employment Application
  1. We will not discriminate based upon race, color, religion, sex, national origin, citizenship, age, height, weight, marital status, veteran status, handicap, or any other protected category.
  2. APPLICANT INFORMATION

  3. Last Name (required):*
    Please share your last name.
  4. First Name (required):*
    Please share your first name.
  5. Middle Initial:
    Please share your middle initial.
  6. Street Address (required):*
    Please share your street address.
  7. Apartment/Unit#:
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  8. City (required):*
    Please share your city.
  9. State (required):*
    Please share your state.
  10. ZIP (required):*
    Please share your ZIP.
  11. Phone (required):*
    Please share your phone number.
  12. Email Address:
    Please share your email address.
  13. Referred by:
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  14. Are you 18 years or older? (required)*

    Please select YES or NO.
  15. Have you ever been convicted of a crime? (required)*

    Please indicate YES or NO.
  16. **If YES, explain:
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  17. ** A conviction will not necessarily be a bar to employment. Factors such as age, time of offense, seriousness and nature of violation, and rehabilitation will be considered.
  18. List states of residence for the past seven years (required):*
    Please list states of residence.
  19. List any names you have used other than given above:
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  1. EMPLOYMENT DESIRED

  2. Position Applying For (required):*
    Please indicate position applying for.
  3. Date Available to Work (required):*
    Please indicate date available to work.
  4. Salary Desired (required):*
    Please indicate salary desired.
  5. Shift Desired (required):*





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  6. Employment Desired (required):*


    Please indicate type of employment desired.
  7. Do you have any objections to working overtime? (required)*

    Please select YES or NO.
  8. Can you travel if required?

    Please select YES or NO.
  9. Have you ever applied with EMSG before? (required)*

    Please select YES or NO.
  10. If YES, when?
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  1. EDUCATION



  2. High School


  3. High School (required):*
    Please enter name of High School.
  4. Address:
    Please enter name of High School.
  5. Phone:
    Please enter High School phone number.
  6. From:
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  7. To:
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  8. Did you graduate? (required)*

    Please indicate YES or NO.
  9. Degree:
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  10. Reason for leaving:
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  11. College


  12. College:
    Please enter name of College.
  13. Address:
    Please enter name of College.
  14. Phone:
    Please enter College phone number.
  15. From:
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  16. To:
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  17. Did you graduate?

    Please indicate YES or NO.
  18. Degree:
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  19. Reason for leaving:
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  20. Other


  21. Other:
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  22. Address:
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  23. Phone:
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  24. From:
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  25. To:
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  26. Did you graduate?

    Please indicate YES or NO.
  27. Degree:
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  28. Reason for leaving:
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  1. PREVIOUS EMPLOYMENT

    LIST MOST RECENT EMPLOYER FIRST


  2. Previous Employer 1


  3. Company:
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  4. Phone:
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  5. Address:
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  6. Supervisor:
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  7. Job Title:
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  8. Starting Salary:
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  9. Ending Salary:
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  10. Responsibilities:
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  11. From:
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  12. To:
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  13. Reason for leaving:
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  14. May we contact your supervisor for reference?

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  15. Previous Employer 2


  16. Company:
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  17. Phone:
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  18. Address:
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  19. Supervisor:
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  20. Job Title:
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  21. Starting Salary:
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  22. Ending Salary:
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  23. Responsibilities:
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  24. From:
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  25. To:
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  26. Reason for leaving:
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  27. May we contact your supervisor for reference?

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  28. Previous Employer 3


  29. Company:
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  30. Phone:
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  31. Address:
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  32. Supervisor:
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  33. Job Title:
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  34. Starting Salary:
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  35. Ending Salary:
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  36. Responsibilities:
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  37. From:
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  38. To:
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  39. Reason for leaving:
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  40. May we contact your supervisor for reference?

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  41. Previous Employer 4


  42. Company:
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  43. Phone:
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  44. Address:
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  45. Supervisor:
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  46. Job Title:
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  47. Starting Salary:
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  48. Ending Salary:
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  49. Responsibilities:
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  50. From:
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  51. To:
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  52. Reason for leaving:
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  53. May we contact your supervisor for reference?

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  1. MILITARY SERVICE

  2. Branch:
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  3. From:
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  4. To:
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  5. Rank at Discharge:
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  6. Type of Discharge:
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  7. **If other than honorable, explain:
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  8. ** A dishonorable discharge from the military will not necessarily be a bar to employment.
  9. REFERENCES



  10. Reference 1


  11. Full Name:
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  12. Years Acquainted:
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  13. Company:
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  14. Phone:
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  15. Address:
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  16. Reference 2


  17. Full Name:
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  18. Years Acquainted:
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  19. Company:
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  20. Phone:
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  21. Address:
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  22. Reference 3


  23. Full Name:
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  24. Years Acquainted:
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  25. Company:
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  26. Phone:
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  27. Address:
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  28. I authorize the references and employers listed on this application to provide you any and all information concerning my previous employment and any pertinent information they may have, and release you and all parties from any liability for any damages that may result from furnishing the same to you.
  29. Authorize (required):*

    Please select YES or NO.
  1. List any professional, trade, business, or civic activities and offices held:
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  2. Describe any special job-related training, skills, and certifications:
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  3. Notice To Applicants

  4. Electronic Manufacturing Services Group, Inc. is an equal opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, sex, religion, national origin, handicap, or marital status. We assure you that your opportunity for employment with us depends solely upon your qualifications. We comply with the Americans With Disabilities Act of 1990. During the interview process, you may be asked questions concerning your ability to perform job related functions. If you are given a conditional offer of employment, you may be required to complete a post-job offer medical history questionnaire and/or undergo a medical examination. If required, all entering employees in the same job category will be subject to the same medical questionnaire and/or examination and all information will be kept confidential and in separate files.

    I understand and agree that my employment is for no definite period and may, regardless of date of payment of my wages and salary, be terminated at any time without any previous notice and if hired, I will be placed on a 60-day probationary period. I further understand that if I am terminated for unsatisfactory work or for any violation of company policies, the employer may seek to contest any unemployment benefit I might attempt to obtain.

    I understand and agree that I may be required to undergo blood and/or urinalysis screening for drug and/or alcohol use as part of our pre-employment process.

    I hereby certify that all information on this employment application along with any resumes that I have submitted to the Company, and any other related papers and answers given during oral interviews are true and correct. I further understand and agree that the Company may make a thorough investigation of my work and personal history. I authorize the receiving and giving of any information requested by the Company during such investigation. I further understand that falsification of any information given by myself or others during an investigation or any derogatory information discovered as a result of this investigation may subject me to immediate dismissal.

    EMPLOYMENT INQUIRY RELEASE

    In conneciton with your application for/continued employment with Electronic Manufacturing Services Group, Inc., on their behalf, CBY Systems Inc. will make inquiries, including but not limited to, your consumer credit history, education, professional licensing, criminal history, driving history, your personal character, abilities, work habits, residence, immigration status, general reputation, performance, experience and other qualities pertinent to your qualifications for employment, including reasons for termination of past employments.

    In compliance with the Fair Credit Reporting Act (FCRA), you are entitled to be informed if an offer of employment is withheld because of information obtained from CBY Systems Inc. and, in the event, upon your written request, we will provide a copy of the report we receive and the FTC notice, "A Summary of Your Rights Under the Fair Credit Reporting Act".

    You will be asked to complete and sign a form, authorizing, without reservation, any party, including, but not limited to, empoyers, consumer reporting agencies, law enforcement agencies, state agencies, institutions and private information bureaus or repositories, contacted by CBY Systems Inc. to furnish any or all of the above mentioned information. Your signature allows a photocopy or fax copy of this authorization to be as valid as the original.

  5. I Agree:

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  1. Invitation to Self Identify (OPTIONAL)

  2. Electronic Manufacturing Services Group, Inc. is and Equal Opportunity Employer. As required by law, we must record certain information to be made a part of our Affirmative Action Program.

    Applicants for employment are also invited to participate in the Affirmative Action Program by reporting their status as handicapped, disabled veteran, veteran of the Vietnam era, male or female or a racial minority. In extending this invitation, you are also advised that: (a) workers (applicants) are under no obligation to respond, but may do so in the future if they choose; (b) responses will remain confidential within the Human Resources Department; and (c) responses will be used only for the necessary information to include in our Affirmative Action Program. We are a company that values diversity. We actively encourage women and minorities to apply. Refusal to provide this information or the information provided will have no bearing on your application and will not subject you to any adverse treatment.

    Please complete the information requested below. Thank you for your cooperation.



  3. Section 1: General Application Information


  4. First Name:
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  5. Last Name:
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  6. Position Applied For:
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  7. Section 2: Please check all that apply


  8. Race or Ethnic Identity:






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  9. Gender:

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  10. **Veteran Status:


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  11. **Other:

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  12. How did you hear of our opening?



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  13. If Other, please explain:
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  14. **Note: According to 41 CFR 60-250.42, there are only two circumstances under which an employer may ask applicants who are Special Disabled Veterans to self-identify on a pre-offer basis:

    1. The invitation is made when the contractor actually is undertaking affirmative action for special disabled veterans at the pre-offer stage; or
    2. The invitation is made pursuant to a Federal, state or local law requiring affirmative action for special disabled veterans.

    According to 41 CFR 60-741.42, there are only two circumstances when an employer may ask a disabled applicant to self-identify on a pre-offer basis:

    1. The invitation is made when the contractor actually is undertaking affirmative action for individuals with disabilities at the pre-offer stage; or
    2. The invitation is made pursuant to a Federal, state or local law requiring affirmative action for individuals with disabilities.