Test

General Information

Date*

Name*

First Middle Last

Last Four Digits of Social Security Number*

Primary Phone*

Secondary Phone*

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Have you lived at your residence for less than five (5) years?*

Yes
No

Lived Here How Long?

Previous Address*

Street Address Address Line 2 City State ZIP Code

Applying to:*

FCC (Indiana), LLC - 555 Industrial Park Road, Portland, IN
FCC (Adams), LLC - 936 East Parr Road, Berne, IN
FCC (North Carolina), LLC - 18000 Fieldcrest Road, Laurinburg, NC
FCC (North Carolina), LLC Friction Paper Plant - 16820 US Highway 401, Laurinburg, NC

If previously employed by FCC, please check all applicable locations OR select “Never Employed by FCC”*

FCC (Indiana), LLC ‐ 555 Industrial Park Road, Portland, IN
FCC (Adams), LLC ‐ 936 East Parr Road, Berne, IN
FCC (North Carolina), LLC ‐ 18000 Fieldcrest Road, Laurinburg, NC
FCC (North Carolina), LLC Friction Paper Plant ‐ 16820 US Highway 401, Laurinburg, NC
Never Employed by FCC

Type of Work Desired?

Available to Work:*

1st Shift
2nd Shift
3rd Shift

Available to Work:*

Full Time
Part Time

Date Available to Work:*

Salary Desired $:

Per Hour/Week/Month

Number of Work Days absent last year (excluding vacation, holidays, and approved LOA):*

List relatives employed by FCC:

How were you referred?

Are you over the age of 18?*

Yes
No

Do you have a valid drivers license?*

Yes
No

Were you in the U.S. Armed Forces?*

Yes
No

What Branch?

Dat of Duty?

Type of Discharge?

Note: A less than Honorable Discharge will not constitute an automatic bar to employment.

Rank at Discharge?

List Duties and Special Training while in the U.S. Armed Forces:

Have you ever been convicted of a crime of any kind other than a minor traffic violation?*

Note: Existence of a conviction will not constitute an automatic bar to employment. We will consider all appropriate circumstances. Note: No expunged or sealed convictions are required to be divulged.

Yes
No

What offenses? Give Date, Place and Disposition.

Are you authorized to work in the United States?*

Yes
No

May we contact your previous employer(s)?

Yes
No

Please explain:*

Since age 16, have you ever been known by any name, other than the name listed on the first part of this application?

Yes
No

Give other name and date changed:*

Can you perform the Essential Functions of the position for which you are applying with or without reasonable accommodations?*

Yes
No

Institution/School:	Location:	From:	To:	Last Year Completed:	Did You Graduate?	List Degree or Diploma:	Course of Study or Major:	Actions
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Company	Address	Position/Title:	Start Date:	End Date:	Salary	Per Hour/Week/Month	Supervisor Name:	Describe the Work That You Did:	Reason For Leaving:	Explanation:	Actions
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Name:	Occupation:	Address:	Phone:	Years Known:	Actions
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Step 1 of 5

General Information

Education & Training

Skills & Licenses

Employment History

Personal References

Additional Comments

Notice

Affidavit