1. Employment Application Form Personal Details Date: ________________________________________________________________ Name: _______________________________________________________________ Phone Day Time: _______________________________________________________ Phone After Hours: _____________________________________________________ Mobile: _______________________________________________________________ E-mail: _______________________________________________________________ Address: ______________________________________________________________ ______________________________________________________________________ Marital Status: _________________________________________________________ Dependants: __________________________________________________________ Position Applied For: ____________________________________________________ Previous Employment History: ____________________________________________ _____________________________________________________________________ _____________________________________________________________________ What do you do in your leisure time? ______________________________________ _____________________________________________________________________ Number of days sick leave taken in the last two years: ________________________ Do you have any criminal convictions or charges pending? _____________________ Length of employment you are seeking: ____________________________________ What do you expect from this position: _____________________________________ _____________________________________________________________________

2. Employment Application Form References and Referrals (Previous employers preferred) What can you offer Blacks Fasteners Ltd? ___________________________________ ______________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Are you willing to present yourself in a well groomed manner on an ongoing basis? _____________________________________________________________________ All information given herein is true and correct. Signed: _____________________________ Date: __________________________ Office Use Only: