Custom Coatings Inc.
P.O. Box 553, Marmora, NJ 08223
An Equal Opportunity Employer
Custom Coatings Inc. Application for Employment - SSL Secure

Contact Information Full name: First Middle Last Present Address: Street: City State zip Business Address: Street: City State zip Telephone Numbers Residence -- Business -- ext.

General Information

Date of Application : Social Security Number#

Type of work desired: Salary Desired:

Types of office machines or factory equipment you operate

If hired how soon can you start work?

Automobile make: Color: License plate number:

When was your last physical examination?: (Day/Month/Year)// Results

Who referred you or what led you to apply?

Do you have relatives with this company?Yes No   If yes, who?

Have you ever been previously employed by this company or one of its affiliates? yes no

When may we contact your current employer for references?

Educational Background

Indicate number of years completed: High School Bachelors Masters START WITH THE MOST RECENT SCHOOL ATTENDED. A.School B. Location Dates Attended From To Courses or Major Subject Diploma or Degree Grade or GPA A. B. A. B. A. B. A. B. A. B.

Additional Educational Information Bachelors curriculum was a: bonafide 4 year program   a 5 year program   other Masters curriculum was a: bonafide 1 year program   a 2 year program   other List any other special vocational skills or training completed

Work History 1. Employer: From: enter Day/Month/Year To: enter Day/Month/Year Salary mo. Address Street City State Zip Full time: Part time Summary of position and duties: Supervisor: Reason for leaving: Please list name and title of person to contact(s) Phone:

2. Employer: From: enter Day/Month/Year To: enter Day/Month/Year Salary mo. Address Street City State Zip Full time: Part time Summary of position and duties: Supervisor: Reason for leaving: Please list name and title of person to contact(s) Phone:

3. Employer: From: enter Day/Month/Year To: enter Day/Month/Year Salary mo. Address Street City State Zip Full time: Part time Summary of position and duties: Supervisor: Reason for leaving: Please list name and title of person to contact(s) Phone:

4. Employer: From: enter Day/Month/Year To: enter Day/Month/Year Salary mo. Address Street City State Zip Full time: Part time Summary of position and duties: Supervisor: Reason for leaving: Please list name and title of person to contact(s) Phone:

Emergency Notification In Case of Emergency, notify: Name Address: Phone