EDUCATION

MILITARY SERVICE

PERFORMANCE OF JOB-RELATED FUNCTIONS

High school(s) Location No. of years attended Did you graduate? Major/minor studied

College(s) Location No. of years attended Did you graduate? Major/minor studied

Graduate school Location No. of years attended Did you graduate? Major/minor studied

Trade, business or correspondence school(s) Location No. of years attended Did you graduate? Major/minor studied

Describe any military service skills that may be relevant to the job you are applying for.

Are you able to perform the essential functions of the job for whichyou are applying with or without accommodation? ❏ Yes ❏ No

Have you ever been convicted of a criminal offense (felony or seriousmisdemeanor)?* ❏ Yes ❏ No How many times?

CRIMINAL HISTORY - A conviction (felonies or serious misdemeanors) will not necessarily disqualify an applicant.

❏ Yes ❏ No

❏ Yes ❏ No

❏ Yes ❏ No

❏ Yes ❏ No

Explain fully each conviction (and guilty or nolo contendere plea)

EG072004 Page 2

REFERENCES - Please give names of three persons not related to you whom you have known at least one year, and include at least two past or present supervisors.

Name Address Phone Years Acquainted

AUTHORIZATION - Important: please read carefully and initial each paragraph before signing.

Initial

______ “I declare under penalty of perjury that the information contained in this application and any resume or otherdocumentation submitted is true and complete to the best of my knowledge.”

______ “I understand that any false information or significant omissions will disqualify me from further considerationfor employment, and will be justification for my dismissal from employment, if discovered at a later date.”

______ “I agree to immediately notify the Company if I should be convicted of any crime while my job application ispending or during my period of employment, if hired.”

______ “I give permission for a pre-employment drug screening exam.”

______ “I give permission for a complete employment background check.”

______ “I understand that after being offered employment I (may/will) be required to take a physical and mentalexamination. I consent to the release of any and all medical information and records that the examining physi-cian requests.”

______ “I understand that, if hired, I may be required to sign a company arbitration agreement.”

______ “I understand that, if hired, I may not hold other employment unless given permission in writing by theCompany.”

Agreement For At-Will Employment______ “ I understand and acknowledge that my employment will be at-will, and may be terminated with or without

cause, and with or without notice, at any time at the option of myself or the Company. Only the President ofthe Company has the authority to enter into an employment agreement for a specified period of time or forthe termination only for cause, and any such agreement must be in writing. Except to the extent I am cov-ered by such a written agreement, I understand and acknowledge that this constitutes the entire agreementbetween me and the Company regarding the term of my employment and supercedes any other oral or writ-ten agreement.”

Compliance With Rules______ “If I become employed, in consideration of my employment, I understand that I must comply with the rules,

regulations, policies and procedures of the Company.”

Release______ “I authorize the investigation of all statements contained in the Employment Application Form (and accom-

panying resume, if any) and further authorize any person, school, current employer (except as expresslynoted), past employer(s), and organizations named in the Employment Application Form (and accompanyingresume, if any) to provide the Company with records, information, and opinion that may be useful in makinga hiring decision. I release all informants from all liability for any damage that may result from furnishinginformation and opinion (which is truthful or made in good faith) to the Company.”

Signature of Applicant Date

*Do not identify marijuana-related misdemeanor convictions occurring more than two years ago or convictions for which the criminal record has been expunged, sealed, oreradicated by the court, or misdemeanor convictions for which any probabtion has been completed and the case dismissed by the court.

Revised May 2012

APPLICANT IDENTIFICATION RECORD

Regulations of the California Fair Employment and Housing Commission require employers to obtain certain information from each job applicant. This form is used to provide each applicant with an opportunity to furnish such information voluntarily. All information that is provided voluntarily will be used only for recordkeeping purposes. Such information will not be used for any discriminatory purposes.

1. Position Applied For: ________________________________

2. Sex: Male _________ Female _________

3. Please Check One:

a. ______ American Indian or Alaskan Native b. ______ Asian or Pacific Islander c. ______ Black / African American d. ______ Hispanic e. ______ Caucasian / White f. ______ Other (please specify): _____________________

4. National origin: _________________________ 5. Date: ______________

Revised: May 2012

DRUG-FREE WORKPLACE &

PRE-EMPLOYMENT TESTING

CONSENT FORM

I understand that Kelly Paper Company is a DRUG-FREE WORKPLACE.

I hereby consent and agree to undergo Kelly Paper Company’s post-offer, pre-

employment testing, which includes urine drug and alcohol screen; a physical

examination; a physical abilities test (PAT) and a background check. I understand that

the results will be provided to Kelly Paper Company management only. I further

understand that without a pre-indicated medically acceptable explanation, any positive

drug screen results will automatically disqualify me from employment with Kelly Paper

Company.

My signature acknowledges that I have read, understand and agree with the above

statement.

____________________________________ Applicant Name (print) ____________________________________ ________________ Applicant Signature Date ____________________________________ _____________________ Witness Signature Date