Section 1: Job Information

Location:

Are you a least 18 years old?

Yes No

Position/Job
Applying For:

Are you eligible to work in the United States?

Yes No

Dates Available
to Start Work:

Will you travel?

Yes No

Section 2: General Information

First Name:

Middle Name:

Last Name:

Present Address:

City: State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip Code: How Long?

Home Phone w/Area Code:

Alternative Phone w/Area Code:

Email Address:

Do you have any relatives employed by TOMRA Pacific, Inc? Yes No

Type of Position: Full-time Part-time

Days Available to Work:

Mon.    Tues.    Weds.    Thurs.    Fri.    Sat.    Sun.

Have you ever been convicted of a felony for which the date of conviction, guilty plea,
or prison release, whichever is more recent, is within the last seven years?

Yes No

Have you applied with this company at any other time?

Yes No

If so, when/where?

Have you worked for this or any other company, served in U.S. Armed Forces, or attended school under a different name(s)? Or are you known by a different name(s)? If yes, what name(s):

Yes No

Have you served or are you currently serving in the U.S. Armed Forces?

Yes No

If YES, please complete below.

Branch: Make Selection Army Navy Marine Corps Air Force Coast Guard National Guard Rank:

Specialty Training:

Section 3: Educational Information

College/Unversity - Name & Location

Graduated: Yes No Grade Completed:

Course of Study:

Business/Technical - Name & Location

Graduated: Yes No Grade Completed:

Course of Study:

High School/Other Training - Name & Location

Graduated: Yes No Grade Completed:

Course of Study:

Section 4: Employment History - please provide most recent first

1. Name of Current or Most Recent Employer:

Employer's Address/City/State/Zip:

Phone w/Area Code:

Job Title: Supervisor's Name:

List Duties:

What is your reason for leaving?

Starting Salary: Ending Salary:

2. Name of Employer:

Employer's Address/City/State/Zip:

Phone w/Area Code:

Job Title: Supervisor's Name:

List Duties:

What is your reason for leaving?

Starting Salary: Ending Salary:

3. Name of Employer:

Employer's Address/City/State/Zip:

Phone w/Area Code:

Job Title: Supervisor's Name:

List Duties:

What is your reason for leaving?

Starting Salary: Ending Salary:

4. Name of Employer:

Employer's Address/City/State/Zip:

Phone w/Area Code:

Job Title: Supervisor's Name:

List Duties:

What is your reason for leaving?

Starting Salary: Ending Salary:

Section 5: Professional/Work References -
List persons who know you well, not relatives or employers.

1. Name:

Relationship: How Long?

Home Phone w/Area Code:

Business Phone w/Area Code:

2. Name:

Relationship: How Long?

Home Phone w/Area Code:

Business Phone w/Area Code:

3. Name:

Relationship: How Long?

Home Phone w/Area Code:

Business Phone w/Area Code:

Statement of Policy:

To: Applicants and Their Reference Sources
Unless TOMRA Pacific, Inc. has an applicant's permission beforehand, it is TOMRA Pacific, Inc.'s policy to contact an applicant's present employer only after the applicant has accepted an employment offer which is conditioned, among other things, upon acceptable background checks, including but not limited to, the circumstances of an applicant's present employment. May we contact your present employer at his time?

Yes No

Authorization:

I certify that the facts contained in this application (an accompanying resume, if any) are true and complete to the best of my knowledge. I understand that any false statement, omissions, or misrepresentation on this application are sufficient cause refusal to hire, dismissal if I have been employed no matter when discovered by TOMRA Pacific, Inc..

I understand that any employment is conditioned on a year criminal background check. I authorize TOMRA Pacific, Inc. To thoroughly investigate all statement contained in my application or resume, and I authorize my former employers, reference and any agencies to disclose information regarding my former employment, character, and general reputation to TOMRA Pacific, Inc., without giving me prior notice of such disclosure. In addition, I release TOMRA Pacific, Inc., any former employers and all reference listed above and any agencies from any claim, demands, or liabilities arising out of or related to such investigation or disclosure.

If you are to be hired by TOMRA Pacific, Inc., you will be required to attest to your identity and employment eligibility, and to present document confirming your identity and employment eligibility. You cannot be hired if you cannot comply with these requirements.

I understand and agree that nothing contained in this application, or conveyed during any interview, is intended to create an employment contract. I further understand and agree that if I am hired, my employment will be “at will” and without fixed terms, and may be terminated at any time, with or without cause and without prior notice, at the option of either myself to TOMRA Pacific, Inc. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon TOMRA Pacific, Inc., unless made in writing.

If I am offered employment, I agree to submit to a medical examination and /or drug test before starting work. If employed, I also agree to submit to a medical examination or drug test at any time deemed appropriate by TOMRA Pacific, Inc. and as permitted by law. I consent to such examinations and tests and request that the examining doctor disclose to TOMRA Pacific, Inc. the results of the examination, which results shall remain confidential and segregated from my personnel file. I understand that my employment or continued employment, to the extent permitted by law, is contingent upon satisfactory medical examinations and drugs tests, and if I am hired a condition of my employment will be that I abided by TOMRA Pacific’s Drug and Alcohol Policy.

I understand that filing out this form does not indicate there is a position open and does not obligate TOMRA Pacific, Inc. to hire. If hired, I agree to abide by all TOMRA Pacific, Inc. work rules, policies, and procedures. TOMRA Pacific, Inc. retains the right to review its policies or procedures, in whole or in part, at any time.

I have read, understand and agree. Yes No

Your Name:

rePLANET | TOMRA Pacific, Inc. | 150 Klug Circle, Corona, CA 92880 | Tel. (951) 520-1700
Human Resource Fax (951)735-0148