Employment Application

LINDE Corporation
O'Hara Industrial Park, 118 Armstrong Road, Pittston, PA 18640 - 570-299-5700

AN EQUAL OPPORTUNITY EMPLOYER

LINDE DOES NOT DISCRIMINATE IN HIRING OR EMPLOYMENT ON THE BASIS OF RACE, COLOR, RELIGIOUS CREED, NATIONAL ORIGIN, SEX OR ANCESTRY, ON THE BASIS OF ANYONE 40 YEARS OF AGE OR OLDER, DISABILITY OR VIETNAM ERA VETERANS, NOR DO WE DISCRIMINATE PAYMENT OF WAGES TO WOMEN AND MEN PERFORMING SUBSTANTIALLY EQUAL WORK. NO QUESTION ON THIS APPLICATION IS INTENDED TO SECURE INFORMATION TO BE USED FOR SUCH DISCRIMINATION.

DATE OF APPLICATION:
POSITION APPLIED FOR:
SALARY EXPECTED:
SOCIAL SECURITY NUMBER:
HOME PHONE NUMBER:
EMAIL ADDRESS:

NAME
LAST:

FIRST:

MIDDLE INITIAL:

PERMANENT ADDRESS		HOW LONG?:
NO:	STREET:	CITY:	STATE:	ZIP:

PREVIOUS ADDRESS (IF WITHIN THE U.S.)		HOW LONG?:
NO:	STREET:	CITY:	STATE:	ZIP:

DATE OF BIRTH:

AGE:

MALE
FEMALE

U.S.CITIZEN?:
YES NO

ALIEN REGISTRATION NO.:

WHAT OTHER NAMES HAVE YOU USED IN PRIOR EMPLOYMENT OR IN SCHOOL?:

IN CASE OF EMERGENCY, NOTIFY: NAME:			TELEPHONE NO:
ADDRESS:	CITY:	STATE:	ZIP:

On what date would you be able to work?

Are you available to work Full-Time Part-Time Shift Work Temporary

Are you on a lay-off and subject to recall? Yes No

Do you have reliable means of transportation? Yes No Explain

List professional, trade business or civic activities and offices held which may conflict with work schedule. (You may exclude those which indicate race, color, religion, sex, or national origin):

Hobbies

Any Mechanical Skills?

Have you ever been convicted of a crime? Yes No If so, list charges, disposition, dates and city:

Give name, address and telephone number of three references who are not related to you and are not previous employers and years acquainted:

AFFIRMATIVE ACTION SURVEY

Government agencies require periodic reports on the sex, ethnicity, handicapped and veteran status of applicant. This data is for analysis and affirmative action only.
Submission of information is voluntary.

Check One: Male Female

Check One of The Following: Race/Ethnic Group White Black Hispanic American Indian/Alaskan Native Asian/Pacific Islander

Check One If Any Of The Following Are Applicable: Vietnam Veteran Disabled Veteran Handicapped Individual

HAVE YOU EVER SERVED IN THE MILITARY SERVICE OF THE UNITED STATES? Yes No					MILITARY SERIAL #:
DATE OF INDUCTION	BRANCH	RANK INDUCTION DISCHARGE	LIST JOB/TYPE OF DUTY	TYPE OF DISCHARGE	DATE OF DISCHARGE	TYPE OF RESERVE MEMBERSHIP

HEALTH: EXCELLENT GOOD FAIR POOR

BLOOD TYPE?

DO YOU HAVE ANY KNOWN PHYSICAL IMPAIRMENTS? YES NO
PLEASE LIST DIAGNOSIS, DURATION, RESULTS AND NAME OF PHYSICIAN:

ARE YOU CURRENTLY UNDER A DOCTOR'S CARE? YES NO
IF YES, LIST NAME AND ADDRESS OF PHYSICIAN:

WOULD YOU BE WILLING TO TAKE A PHYSICAL EXAMINATION AT OUR EXPENSE? YES NO

HAVE YOU MADE ANY WORKMAN'S COMPENSATION CLAIMS WITHIN THE PAST FIVE YEARS? YES NO
IF YES, LIST NATURE, DURATION, NAME OF EMPLOYER, DATES:

DID YOU EVER RECEIVE AN AWARD BASED ON PERMANENT DISABILITY? YES NO
IF YES, GIVE DATE OF RELEASE:

NOTE: The sole purpose in inquiring into the applicant's physical condition and health history is to determine whether or not he/she suffers from any physical defect or impairment which could affect ability to perform the job for which he/she is applying.

Any Driving violations in the past 3 years? Yes No
If Yes, why:

Class of License?

Do you have any physical defects which preclude you from performing certain kinds of work? Yes No
If yes, describe such defects and specific work limitations:

Have you had a major illness in the past 5 years? Yes No
If yes, describe:

Have you received compensation for injuries? Yes No
If yes, describe: