Flexsteel Industries, Inc.

Application for Employment

Date:
First Name:
Middle Initial:
Last Name:
Present Address:
City:
State/Province:
Zip/Postal Code:
Phone Number:
Email:

Can you, after employment, submit verification
of your legal right to work in the United States?
Yes No

Have you ever been convicted of a crime,
other than a traffic violation?
Yes No
(The existence of a criminal record will not automatically disqualify an applicant from employment. The circumstances of a conviction will be considered in relation to the nature and duties of the job for which you apply. Failure to disclose will result in disqualification from employment.)
If yes, please explain:

Position Applied For:

Available to Work:
Full-Time Part-Time Either
Shift Preferred:
Days 2nd Shift

Salary Expected:
On what date will you be available to work?

Have you previously been employed by Flexsteel?
Yes No
If yes, what dates?

List any equipment you are qualified to operate:
Industrial Equipment:
Office Skills / Equipment:
Computer Skills:
PC Mac Both
Computer Applications (list all that apply):
Other Skills:

Flexsteel is an equal opportunity / affirmative action employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. We welcome and encourage diversity in our workforce.

Applicants requiring reasonable accommodation in the application and / or interview process should notify a representative of the organization.

Record of Education

Type of School Name of School Complete Mailing Address Course of Study Num. Years Completed Did You Graduate? List Degree or Diploma
High School or G.E.D. YesNo
College/University YesNo
Other YesNo

Previous Employment (List Up To 4)

List below all present and past employment, beginning with your most recent.

1.
Name of Employer:
Complete Mailing Address:
Phone Number:
Last Job Title:
Last Supervisor's Name:
Dates of Employment: From:   To: 
Salary: Starting:  Ending: 
Reason for Leaving (Be Specific):
List the jobs you held, duties performed, skills used or learned, and advancements or promotions while you worked at this company:
May we contact this employer? YesNo

2.
Name of Employer:
Complete Mailing Address:
Phone Number:
Last Job Title:
Last Supervisor's Name:
Dates of Employment: From:  To: 
Salary: Starting:  Ending: 
Reason for Leaving (Be Specific):
List the jobs you held, duties performed, skills used or learned, and advancements or promotions while you worked at this company:
May we contact this employer? YesNo

3.
Name of Employer:
Complete Mailing Address:
Phone Number:
Last Job Title:
Last Supervisor's Name:
Dates of Employment: From:  To: 
Salary: Starting:  Ending: 
Reason for Leaving (Be Specific):
List the jobs you held, duties performed, skills used or learned, and advancements or promotions while you worked at this company:
May we contact this employer? YesNo

4.
Name of Employer:
Complete Mailing Address:
Phone Number:
Last Job Title:
Last Supervisor's Name:
Dates of Employment: From:  To: 
Salary: Starting:  Ending: 
Reason for Leaving (Be Specific):
List the jobs you held, duties performed, skills used or learned, and advancements or promotions while you worked at this company:
May we contact this employer? YesNo

Business or Educational References (Please List 3)

Name
Position
Company
Telephone

How did you learn about this position?
Company Website Newspaper
State Employment Office Access Dubuque
Other   (Please Specify): 


PLEASE READ CAREFULLY
APPLICANT'S CERTIFICATION AND AGREEMENT

In consideration of being employed, I understand and agree that:

  1. If I misrepresent or deliberately leave out a fact in my application, I may be refused employment or, if employed, I may be terminated.
  2. The Employer has my authorization to thoroughly investigate my background by checking with references, former employers, educational institutions, law enforcement agencies, and governmental agencies, and I hereby consent to take any test whenever the Employer deems it necessary in any Employer investigation. I will hold no person, corporation, or organization liable for my giving or its receiving information in such investigation.
  3. If employed, I may terminate my employment without notice or cause, and the Employer may terminate or modify the employment relationship at any time without prior notice or cause. In consideration of my employment, I agree to conform to the rules and regulations of the Employer, and I understand that no department head or representative of the Employer, other than the President, has any authority to enter into any agreement, oral or written, for employment for any specified period of time or to make any agreement or assurances contrary to this policy.
  4. Any doctor, hospital, or testing laboratory has my consent to conduct medical or drug tests on me, and I hereby give my consent to having all information released for the Employer to determine my abilities to perform job duties now or in the future.
  5. The needs of the Employer may make the following conditions mandatory: overtime, shift work, rotating work schedule, or a work schedule other than Monday through Friday. I accept these as conditions of employment.
  6. The Employer is an equal opportunity / affirmative action employer. The Employer does not discriminate in employment and no question on my employment application is used for the purpose of limiting or excluding any applicant's consideration for employment on a basis prohibited by local, state, or federal law.
  7. If employed, I understand that my employment is for no definite period of time, and if terminated, the Employer is liable only for wages or salary earned as of the date of termination.
  8. This application is current and active for six months. At the conclusion of this time, if I have not had any contact from the Employer and still wish to be considered for employment, it will be necessary for me to fill out a new application.
  9. All employment offers are made contingent upon satisfactory proof of legal authorization to work in the United States according to the law. I understand that failure to provide satisfactory proof of identity and authorization to work in the United States will disqualify me from employment.

  I have read and agree to the above and hereby certify that the facts I have provided in my employment application are true and complete.

Applicant / Electronic Signature
(Type in your name)		 Date
(Type in today's date)



Employment Data Record for Flexsteel Industries, Inc.

Applicants for employment, as well as employees, are treated without regard to race, color, religion, sex, national origin, age, marital or veteran status, medical condition or disability, or any other legally protected status.

As required, we comply with government regulations including Affirmative Action obligations where they apply.

The purpose of this Data Record is to comply with government record keeping, reporting, and other legal requirements. Periodic reports are made to the government on the following information. The completion of this Data Record is optional. If you choose to volunteer the requested information, please note that all Data Records are kept in a confidential file and are not a part of your Application for Employment or personnel file.

PLEASE NOTE: YOUR COOPERATION IS VOLUNTARY. INCLUSION OR EXCLUSION OF ANY DATA WILL NOT AFFECT ANY EMPLOYMENT DECISION.

VOLUNTARY SURVEY

Government agencies at times require periodic reports on the sex, ethnicity, disability, veteran, and other protected status of employees. This data is for statistical analysis with respect to the success of the Affirmative Action Program. SUBMISSION OF THIS INFORMATION IS VOLUNTARY.

Check one: Male Female
Check one of the following (ethnic origin): Hispanic or Latino White Asian American Indian or Alaskan Native
Black or African American Native Hawaiian or Pacific Islander 2 or more races