Prospective employees will receive consideration without
discrimination because of race, religion, color, sex, age,
national origin, disability, genetic information, veteran status
or any other protected status.
An Equal Employment
Opportunity Employer
APPLICATION FOR EMPLOYMENT
PLEASE PRINT OR TYPE
Please note that falsifying, misrepresenting or omitting any information (as determined in the sole
discretion of Polygon Company (“Polygon”)) as part of the application process may result in you
not being considered for employment. If the information is discovered after you are employed, it
may result in disciplinary action, up to and including termination of your employment. This
includes, but is not limited to, falsifying, misrepresenting or omitting any information provided on
your resume, application, during an interview, as well as any other information submitted as part
of the application process.
Please answer all questions. Resumes are not a substitute for a completed Application.
This application remains current for 60 days. If an applicant remains interested in being considered for employment after the
expiration of this period, the applicant should inquire as to whether or not applications are being accepted at that time.
PERSONAL:
Last Name
First
Middle
Street Address
Date
Home Phone
(
City, State, Zip
)
Business Phone
(
! Yes
Have you ever worked for Polygon?
! No
)
Have you ever applied at Polygon?
! Yes
If yes, when?_____________________
If yes, when?_____________________
Position for which you are Applying:
:
Expected Salary/Hourly Pay Rate:
Type of employment desired:
! Full-time Part-Time (specify hours)
_____________
! No
Will you work overtime if asked?
! Yes
! No
Are there any days, hours or shifts you are unavailable to work?
_________________________
Are you over 18 years of age?
! Yes
! No
(If not, employment is subject to verification of eligibility to work/work certificate.)
Are you legally eligible for employment in the United States? ! Yes
(Proof of work authorization status will be required upon employment)
When will you be available to begin work?
! No
Do you possess any special training or skills (language, machine operation, etc.) that you believe would assist you in the position for which you are
applying?
Have you been convicted of a felony in the past seven years which has not been annulled, expunged or sealed by a court?
! Yes
! No
If Yes, describe in full.*
*A prior conviction will not necessarily result in a decision not to hire. Polygon will consider, among other factors, the nature and seriousness of the
offense, the time that has passed since the conviction and/or completion of the sentence and the nature of the job you are seeking.
EDUCATION:
SCHOO
L
NAME AND LOCATION OF SCHOOL
COURSE
OF STUDY
NO. OF
YEARS
COMPLETED
DID YOU
GRADUATE?
DEGREE OR
DIPLOMA
Yes
High
School
No
Yes
No
College
Bus./Tech/
Trade or
Post
College
Yes
No
EMPLOYMENT HISTORY:
Please provide all information for all past employment you have held in the past ten (10) years and your past three (3) employers. In the event that
information about your past three (3) employers falls beyond the ten (10) year time frame, please still respond fully regarding that employer(s).
Account for all periods of time, including any period of unemployment. If self-employed, supply firm name and business references. If you need
additional space, please use an additional sheet of paper. Your failure to completely respond to each inquiry may disqualify you for consideration
from employment.
1)
Employer Name
Address
Telephone
(
)
Employed (State Month and Year)
Name of Supervisor
From
Pay
To
Start
Last
Reason for Leaving (If resignation, please identify
duration of notice given.)
State Job Title and Describe Your Work Duties:
May we contact this employer?
2)
Employer Name
Address
Telephone
(
)
Employed (State Month and Year)
Name of Supervisor
From
Pay
To
Start
Last
Reason for Leaving (If resignation, please identify
duration of notice given.)
State Job Title and Describe Your Work
May we contact this employer?
3)
Employer Name
Address
Telephone
(
)
Employed (State Month and Year)
Name of Supervisor
From
Pay
To
Start
Last
Reason for Leaving (If resignation, please identify
duration of notice given.)
State Job Title and Describe Your Work
May we contact this employer?
REFERENCES:
Name
Telephone
Years Known
APPLICANT CERTIFICATION: DO NOT SIGN UNTIL YOU HAVE READ THE STATEMENT
I understand and agree that if driving is a requirement of the job for which I am applying, my employment and/or continued
employment is contingent on possessing a valid driver’s license and carrying personal automobile liability insurance in an
amount directed by the Company based on the state where I reside.
I understand that Polygon has a drug-free workplace policy and conducts substance abuse /fitness-for-duty testing in
accordance with applicable federal, state, and local law. If I am made an offer of employment, I understand that the offer is
contingent upon my passing a pre-employment (post-offer) drug test. If I test positive or if I do not report to the collection
facility as instructed, Polygon may withdraw the employment offer. I also understand that if I am employed by Polygon I
will be subject to Polygon’s drug-free workplace and fitness-for-duty policies. As part of those policies I understand that I
may be subject to drug and alcohol testing, consistent with applicable federal, state, and local law.
I UNDERSTAND THAT NEITHER THIS APPLICATION NOR ANY COMMUNICATION OR CORRESPONDENCE
FROM POLYGON (I.E., HANDBOOK, POLICY MANUAL, GENERAL POLICIES AND PROCEDURES) IS
INTENDED TO CREATE OR DOES CREATE A CONTRACT OF EMPLOYMENT, OFFER OR PROMISE OF
EMPLOYMENT FOR A DEFINITE TERM. I ACKNOWLEDGE THAT IF HIRED BY POLYGON, EMPLOYMENT IS
ON AN AT-WILL BASIS. THIS MEANS POLYGON IS FREE TO TERMINATE MY EMPLOYMENT AT ANY TIME,
WITH OR WITHOUT CAUSE AND WITHOUT ADVANCE NOTICE, IN ACCORDANCE WITH LOCAL, STATE AND
FEDERAL LAW, AND ACCEPTANCE OF EMPLOYMENT IS NOT A CONTRACT OF EMPLOYMENT FOR ANY
SPECIFIED DURATION. SIMILARLY, I AM FREE TO TERMINATE MY EMPLOYMENT WITH POLYGON AT
ANY TIME FOR ANY REASON. THIS AT-WILL PROVISION MAY BE MODIFIED OR WAIVED ONLY IN A
WRITTEN AGREEMENT SIGNED BY THE PRESIDENT AND CEO OF POLYGON. I ALSO UNDERSTAND THAT
POLYGON HAS COMPLETE DISCRETION TO MODIFY ITS RULES AND REGULATIONS, POLICIES AND
PROCEDURES, BENEFITS PLANS AND COMPANY PROGRAMS AT ANY TIME IT SEES FIT
I certify that the information set forth in my application for employment is true, accurate, and complete. I authorize Polygon
to verify information I provide as part of the application process and conduct any background checks or investigations it
deems appropriate and job-related, including a criminal background check and investigation of my personal history and
financial and credit record. I understand that I will be asked to sign a separate consent to such investigations and background
checks to the extent they are conducted by a third-party. I release, discharge and hold harmless, to the extent permitted by
federal, state, and local law, any party delivering information to Polygon or its agents from any liability, claims, charges, or
causes of action I may have as a result of the delivery or disclosure of any investigations or background checks.. I also
release from liability Polygon and its representatives for seeking such information, as well as all persons, corporations, or
organizations furnishing such information.
I certify that I have read, fully understand and accept the terms of the foregoing Applicant
Certification.
_______________________________
Date
_____________________________________
Signature