Chesterfield, MichiganPersonal DataName:(Required) First Last Address:(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Phone:(Required)Alternate Phone:Email Address(Required) Job InterestDesired Position:(Required)Electronics AssemblerElectronics Test TechnicianQuality Control InspectorSMT OperatorDesired Shift:(Required) Full Time Part Time Intern Desired Start Date:(Required) Month Day Year How did you hear about us?Select a ChoiceEmployee ReferralIndeed.comBillboard AdvertisementOtherEmployee Name: The employee who told you about the opportunity.Have you ever been employed by Riverside Mfg., LLC before?(Required) Yes No If yes, when & in what position: Are you a US Person? (US Citizen, US Permanent Resident or Refugee/Asylum Seeker)?(Required) Yes No Are you at least 18 years of age?(Required) Yes No Have you ever been discharged or asked to resign by an employer?(Required) Yes No If yes, please explain: Have you ever been convicted of a felony?(Required) Yes No If yes, please explain: ( A positive response will not necessarily disqualify an applicant from employment. )EducationHigh School/GEDName & Location: Areas of Study: Graduated? Yes No Enrolled College/UniversityName & Location: Areas of Study: Graduated? Yes No Enrolled Business, Trade, TechnicalName & Location: Areas of Study: Graduated? Yes No Enrolled OtherName & Location: Areas of Study: Graduated? Yes No Enrolled Employment History( Please provide a complete record of your employment history beginning with your present or most recent position. )Company Name: Business Type: Address: Supervisor: Supervisor Title: Position: Shift: Full Time Part Time Temporary Start of Employment: Month Day Year End of Employment: Month Day Year Ending Salary:Numeric Value OnlyReason for Leaving: May we contact? Yes No Description of Duties:Company Name: Buisness Type: Address: Supervisor: Supervisor Title: Position Title: Shift: Full Time Part Time Temporary Start of Employment: Month Day Year End of Employment: Month Day Year Ending Salary:Numeric Value OnlyReason for Leaving: May we Contact? Yes No Description of Duties:Company Name: Business Type: Address: Supervisor: Supervisor Title: Position Title: Shift: Full Time Part Time Temporary Start of Employment: Month Day Year End of Employment: Month Day Year Ending Salary:Numeric Value OnlyReason for Leaving: May we contact? Yes No Description of Duties:Professional ReferencesPlease list up to 3 professional references(Required)NameCompany & TitleTelephone # Add RemovePhoneThis field is for validation purposes and should be left unchanged.
