This application will remain valid for 180 days. Please fill out the information below. We thank you for your continued interest in Staco Energy Products Co.

Tell us about yourself:

Name in Full: 

Present Address: 

Phone:    Own        Message

Social Security Number:

Are you between 18 and 65 years of age?     Yes      No

Type of work desired: 

Do you have any physical limitations that would, without reasonable accommodations, affect your ability to do the job for which you are applying?
     Yes        No

If Yes, please explain:

In case of emergency, please notify: 

Work Experience (start with most recent)

Dates of Employment:
    From:        To: 

Company Name and Address:

Work/Duties Performed:

Wage/Salary:  

Reason for leaving: 

Dates of Employment:
    From:        To: 

Company Name and Address:

Work/Duties Performed:

Wage/Salary:  

Reason for leaving: 

Dates of Employment: 
   From:        To: 

Company Name and Address:

Work/Duties Performed:

Wage/Salary:  

Reason for leaving: 

Dates of Employment:
    From:        To: 

Company Name and Address:

Work/Duties Performed:

Wage/Salary:  

Reason for leaving: 

If you need more entry space, please fax your resume to 937-253-1793, or email it to jobs@stacoenergy.com

Do you read blueprints?    Yes       No 

Schematic diagrams?       Yes       No: 

Please list any machinery or equipment you are able to operate:

Do you type?    Yes       No        WPM 

Please list any software and/or office equipment you are able to operate:

Have you ever worked for Staco Energy Products Co.before?   Yes        No 

Referred by:   Advertisement Internet Search Engine Staco Energy Products Co. Website Friend/Relative Ohio Bureau of Employment Services Other Please tell us how you heard about us.

Are you presently employed?    Yes        No 

May we contact your present employer for a reference?    Yes        No 

If hired, what date could you report to work?  

Starting pay rate expected: 

Educational Background

High School:        

City/State:

Highest Grade Completed:  9 10 11 Graduated Did Not Attend

Major Area of Studies: 

College/Tech. School:  

City/State: 

Highest Grade Completed:  1 2 3 4 Graduated

Major Area of Studies: 

College/Tech. School:  

City/State: 

Highest Grade Completed:  1 2 3 4 Graduated

Major Area of Studies: 

Other: 

City/State: 

Verification Code:

By submitting this form, I declare that all the above information is a true and complete statement of facts, with the understanding that it will be investigated, and if found false, will constitute sufficient grounds for termination of my employment.  I further agree to be governed and to abide by company rules and regulations.