EMPLOYMENT / UNEMPLOYMENT HISTORY
From
To
List below all present and past employment starting with your most recent employer. Account for all periods
of unemployment. You must complete this section even if attaching a resume.
Employer
Employment
Application
Telephone
(
)
Job Title
Address
Immediate Supervisor
Your Position and Duties
(if you fill this out...you better mean it.)
PLEASE PRINT
Reason for Leaving
Weekly Pay
Please, DO NOT CONTACT
Starting ______________ Ending _____________
From
To
Job Title
Employer
Telephone
(
)
Immediate Supervisor
Position (s) Applied For
/
/
LAST
FIRST
MIDDLE
Address
Your Position and Duties
STREET
Telephone (
Reason for Leaving
CITY
)
STATE
Social Security Number
-
ZIP CODE
-
Email address _______________________________________________________________
Weekly Pay
Please, DO NOT CONTACT
Starting ______________ Ending _____________
To
Date of Application
Name
Address
From
Hagie Manufacturing Company
P.O. Box 273 - 721 Central Avenue West - Clarion, Iowa 50525
515-532-2861
We are a High Performing Unconventional Company
Employer
Verify email address __________________________________________________________
Telephone
(
)
Job Title
Address
Immediate Supervisor
Your Position and Duties
NOT NEEDED IF YOU WROTE IT LEDGIBLY THE FIRST TIME
PERSONAL INFORMATION
How did you hear about this opening? ________________________________________________________________________
Reason for Leaving
Please, DO NOT CONTACT
Starting ______________ Ending _____________
From
To
YES NO
Have you ever applied to or worked for Hagie before?
Weekly Pay
Employer
If yes, when? _______/________/________
Telephone
(
)
Do you have any friends or relatives working for Hagie?
Job Title
Address
Immediate Supervisor
Your Position and Duties
YES NO
______________________________________ Referral Source: YES NO
NAME
______________________________________ Referral Source: YES NO
Reason for Leaving
NAME
Weekly Pay
Please, DO NOT CONTACT
Starting ______________ Ending _____________
Name
Telephone
Years Known
Area Code
(
)
AUTHORIZATION AND RELEASE ( Please read carefully, Initial Each Paragraph and Sign Below )
I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of
my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application
or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.
I hereby authorize the company to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the references I
have listed to disclose to the company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby
release the company, my former employers and all other persons, corporations, partnerships and associates from any and all claims, demands or liabilities arising out of or in any way related to
such investigation or disclosure.
______
 Seasonal
Will you work overtime, if required?
YES NO
Are you excited about the possibility of overtime, if required?
YES NO
Have you been convicted of a felony in the last seven (7) years?
YES NO
(Such conviction may be relevant if job related, but does not bar you from employment.)
If yes, please explain:_____________________________________________________________________________________
How many unscheduled or unexcused absences per year do you think are acceptable? __________________________________
SKILLS AND QUALIFICATIONS
I understand that nothing contained in the application, or conveyed during any interview which may be granted during my employment, if hired, is intended to create an employment contract
between me and the company. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or
without prior notice, at the option of either myself or the company, and that no promises or representations contrary to the forgoing are binding on the company unless made in writing and
______
Temporary
Either
Date available for work  ASAP  2 Weeks  Other __________________________________________________________
Area Code
(
)
______
(Proof of U.S. citizenship or immigration status will be required upon employment.)
Type of employment desired
 Full Time
 Part-Time
Type of shift desired
 First only
 Second Only
Area Code
(
)
______
YES NO
YES NO
Are you 18 years or older?
Are you legally eligible for employment in this country?
REFERENCES ( Non-family or Relatives )
Summarize special skills and qualifications acquired from employment or other experiences that may qualify you for work with our company.
______________________________________________________________________________________________________________________________________________
signed by me and the company's designated representative.
______________________________________________________________________________________________________________________________________________
I understand that, if offered a position, I will be required to meet the Company's pre-employment drug screening requirement and pass the physical capacity profile testing.
______________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________
Signature of Applicant
Date
/
/
AN EQUAL OPPORTUNITY EMPLOYER
DRAW IN HERE:
HAGIE FAMILY VALUES
CREATIVITY
1.
2.
3.
4.
5.
6.
7.
8.
9.
In this section we ask you to DRAW.
Either the “Mr. Turtle” figure you see
here in the open box to its right or an
original drawing of your favorite hobby.
There is no right or wrong answer we are
just looking at your level of creativity.
Deliver WOW
Be Passionate and Determined
Pursue Growth and Learning
Respect, Trust, and Honesty for Everyone
Build a Positive Team and Family Spirit
Embrace and Drive Change
Create Fun and Be Adventurous
Do More with Less
Be Humble
We, the Hagie employees, have derived this simple list of values we operate by every day. It guides us in our decision making and it drives us to keep evolving
into better employees and in turn better people. You will find we do things a little different here and we want to keep it this way. We want all employees to
want to come to work...everyday. Anyone we invite to be part of the Hagie Family will need to live by these values as well. WE HIRE AND FIRE BY THEM
The finished drawing is then the property of Hagie
Mfg. We might make t-shirts or coffee cups. It is
hard to say, just know we really appreciate your
participation in showing your creative side.
If you are left-handed, feel free to
flip the page upside down.
We realize you may not know the complete definition of the values above, still we would like you to pick one and tell us what it
means to you.
CRITICAL THINKING
Value #: _______________________________________________________________________________________________
Choose the Number that is 1/4 of 1/2 of 1/5 of 200:
What does it mean to you?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
2
5
10
50
Mary is sixteen years old and is four times as old as her brother. How old will Mary be when she is twice as old as her brother?
20 24 25 26 28
Which one of the five choices makes the best comparison? PEACH to HCAEP as 46251 is to:
25641 26451 12654 51462 15264
Which one of the following things is the least like the others?
Poem Novel
QUESTIONS THAT MAKE YOU GO “Hmm?”
25
If you were a super hero and you had super powers...What would your super powers be and Why?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Painting
Statue
SCRATCH AREA: (Please show your work, if needed.)
How lucky in life do you consider yourself on a scale of 1-10?
Why?
_____________________________________________________________________
______________________________
Example: 1 = “I don't know why, but bad things always seem to happen to me.”
5 = “I’m about as lucky as the average person.”
10 = “I don't know why, but good things always seem to happen to me.”
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
EDUCATIONAL BACKGROUND
Name and Location
Years Completed
Did you Graduate?
Course of Study
High School
College
Major
Other
Are you satisfied with your educational accomplishments?
How many four-sided figures appear in the diagram above?
10 16 22 25 28
If all Bloops are Razzies and all Razzies are Lazzies, then all
Bloops are definitely Lazzies?
True False
Degree
YES NO
If not, what would you change?
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Flower
What is the missing number in the sequence shown below?
1 - 8 - 27 - ? - 125 - 216
35 45 46 64 99
Did you guess at any of the questions in this Critical Thinking
section?
Yes No
AN EQUAL OPPORTUNITY EMPLOYER