* Are you legally eligible to be employed in the United States? (Proof of identity and eligibility will be required upon employment):

Yes   No

* Will you now or in the future require sponsoring for employment visa status (e.g., H-1B visa status etc.)?:

Yes   No

* Are you at least 18 years or older? (If no, you may be required to provide authorization to work):

Yes   No

* Have you ever worked for this Company before?:

Yes   No

If Yes, please provide details (Where/When/Job Title):

* Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation?:

Yes   No

If no, please explain:

Are you related to an Amphenol employee?:

Yes   No

If yes, please give name and location:

If you were referred to this job by a current Amphenol employee, please list the employees name here for our referral program:

* When would you be available to begin work?:

* Type of employment desired:

Full-Time Part Time Seasonal

* Salary/Hourly rate desired:

* Are you currently employed?:

Yes   No

* If so may we inquire of your present employer?:

Yes   No

If presently employed, why are you considering leaving?:

Give record of all High Schools, Colleges, Universities and Vocational/Technical Schools you have attended.

School Name & Location	Did you Graduate?	Degree Received	Subjects Studied/Major
*	* Yes   No	*	*
*	* Yes   No	*	*
	Yes   No

Give your full employment record, starting with your current or most recent employment

Dates Employed	Employer Name & Address	Employer Phone
From: * To: *	* *	*
Job Title	Supervisor Name & Title	May we Contact?
*	* *	* Yes No
Responsibilities	Reason for Leaving
*	*

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Job Title	Supervisor Name & Title	May we Contact?
		Yes No
Responsibilities	Reason for Leaving

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Job Title	Supervisor Name & Title	May we Contact?
		Yes No
Responsibilities	Reason for Leaving

Name	Relationship	Phone Number	Email
*	*	*	*
*	*	*	*
*	*	*	*

I hereby certify that the answers and statements given by me in this application are correct without consequential omissions of any kind. I understand and agree that a false statement or omission constitutes sufficient cause for withdrawal of any employment offer or my immediate dismissal from employment resulting from this application. I understand and agree that employment by the Company or any of its subsidiaries is conditional upon satisfactory completion of a post-offer physical examination including a post-offer drug test and periodic drug testing where authorized by law and the execution of an intellectual property agreement. If an offer of employment is tendered, it is conditional upon my submittal of documents which prove my work eligibility. These documents are due in three (3) business days from the tender of the offer.
I authorize all persons and companies named above, except my present employer if so noted, to furnish any information regarding me whether or not it is on the records and hereby release them and the Company from all liability for damage and otherwise authorize investigation of all statements contained in this application for employment as they are required to aid the Company in arriving at a fair objective employment decision. I understand that this application in no way constitutes a contract of employment, and that my employment may be terminated by myself or the Company at any time. It is further understood that unilateral statements of policy which appear or may appear from time to time in employment handbooks, manuals, or other Company publications shall not be construed to modify in any way the explicit provisions of the above statement.

I agree to abide by all Company rules, regulations, policies and procedures.

* Signature (type name):

* Date: