QUADAX, INC. EMPLOYMENT APPLICATION You must be using Adobe Reader® Version 7 or later to submit this form by e-mail. You can also fill out the form, print it, and send it to Quadax by mail. We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, creed, color, age, sex, religion, handicap, national origin, military or veteran status, pregnancy or any condition prescribed by law. Quadax does not hire persons who use tobacco products, including cigarettes, cigars, pipes, or smokeless tobacco. Applicants will be required to provide a written certification regarding their status as nonusers of tobacco products, and will be subject to testing to confirm that status if hired. Submit by e-mail Date: Personal Information First Name: Last Name: Middle Initial: Address: State: City: Home Phone Number: Zip Code: Business Phone Number + Ext: Former Last Names: SSN: Former Address: (Last 5 Years) State: City: Zip Code: Referred By: Are you eligible for employment in the United States? Yes No Position Applied For: Date Available For Work: Are you available for full-time work? Yes No If No, what hours can you work? Are you currently employed? Yes Have you previously applied here? Did you interview? Yes No No Yes May we contact your current employer? No Yes No If Yes, when? If Yes, with whom? Have you used any tobacco product, including cigarettes, cigars, pipes or smokeless tobacco, at any time in the last 90 days? Yes No Page 1 of 4 10/16/2014 Have you been convicted of a felony or of any misdemeanor other than a traffic offense? No Yes If Yes, provide date and place of conviction, and type of crime. (A conviction will not necessarily be a bar to employment.) Education Name and Location of School Did you Course of Study Completed graduate? Degree or Diploma Graduate College Business/ Trade/ Technical High School General Describe any other special job-related skills or training: Do you have a valid driver's license? Yes License Number: Military Service or Armed Forces? No State of Issue: Yes No If Yes, which branch? Describe the military training received relevant to the position for which you are applying: Additional Information Membership in professional and civic organizations, special accomplishments, awards, etc. Exclude those which may disclose your race, color, religion, age, or national origin. Page 2 of 4 10/16/2014 Employment Please give accurate, complete full-time and part-time employment records. Start with your present or most recent employer. Company Name: Phone Number: Address: City: Employed From (Month & Year) State: To Zip Code: Earnings (Hourly or Annual): Job Title and Description: Reason for Leaving: Company Name: Phone Number: Address: City: Employed From (Month & Year) State: To Zip Code: Earnings (Hourly or Annual): Job Title and Description: Reason for Leaving: Company Name: Phone Number: Address: City: Employed From (Month & Year) State: To Zip Code: Earnings (Hourly or Annual): Job Title and Description: Reason for Leaving: Company Name: Phone Number: Address: City: Employed From (Month & Year) State: To Zip Code: Earnings (Hourly or Annual): Job Title and Description: Reason for Leaving: May we contact the employers listed above for reference purposes? If No, which employer and why? Page 3 of 4 10/16/2014 Emergency Contact Name: Relationship: Address: City: Home Phone Number: State: Zip Code: Business Phone Number: Applicant's Agreement I certify that answers given herein are true and complete to the best of my knowledge. I understand that incomplete, false or misleading information given in my application, resume, or interview(s) is cause for termination and / or ineligibility for employment. I agree to abide by all rules and regulations of the Company. I understand that if hired by Quadax, my employment is at-will and that employment may be terminated by either party at any time with or without cause and with or without notice. By signing below, I accept this agreement and authorize investigation of all statements contained in this application for employment (as may be necessary) in arriving at an employment decision. I authorize the company to check personal and employment references and conduct credit and background checks. You may sign your application at the time of the interview or electronically sign. Signature: Date: Page 4 of 4 10/16/2014