Application for Employment

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: 

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.