Galloway Company

Employment Application F-HR-004-C Page 1 of 9 9/18/2012

This document contains trade secret/confidential commercial information pursuant to 5 U.S.C 552(b)(4)

EMPLOYMENT APPLICATION
Galloway Company 601 South Commercial Street, Neenah, WI 54956 Phone (920) 722-8903 Fax (920) 722-1927 Personal Information Last Name First Name Address City Email Address Positions Applied For: (PLEASE CHECK ONE) Clerical (Specify) Professional (Specify) Managerial (Specify) Zip Code M.I. Date Drivers License # Home Phone Other Phone

Production Worker Technical (Specify) Other (Specify)

Available: Year Round ______Summer Only ______ If you require any reasonable accommodation to complete this form or any part of the application or selection process, please contact the Personnel Office at 920-722-7741 or fax 920-722-1927. Thank you. Office Use Only: Contacted: _____________________ Interviewed: ________________________________

Comments:_________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ _________________________________________________________________________________________

Galloway Company
Employment Application F-HR-004-C Education & Training: Education: Elementary School Name City, State High School College/University Page 2 of 9 9/18/2012 Post Grad
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Years Completed Diploma/Degree Specialized Training, Skills, Extra-Curricular Activities Character References: Please list (3) persons not related to you, that have known you for at least (6) months, and have knowledge of your character, experience, and ability. Name Occupation Home Address City, State, Zip Home/Cell Phone Name Home Address City, State, Zip Home/Cell Phone Name Home Address City, State, Zip Home/Cell Phone Business Address City, State, Zip Business Phone Occupation Business Address City, State, Zip Business Phone Occupation Business Address City, State, Zip Business Phone

Galloway Company
Employment Application F-HR-004-C Page 3 of 9 9/18/2012
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EMPLOYMENT EXPERIENCE:
Please start with your present of most recent job first. Employer Duties Performed: Address City, State, Zip Job Title Supervisor Reason for Leaving Dates Employed: Hourly Rate/Salary: Employer Address City, State, Zip Job Title Supervisor Reason for Leaving Dates Employed: Hourly Rate/Salary: May we contact this employer for references? May we contact this employer for references? Duties Performed:

Galloway Company
Employment Application F-HR-004-C Page 4 of 9 9/18/2012
This document contains trade secret/confidential commercial information pursuant to 5 U.S.C 552(b)(4)

EMPLOYMENT EXPERIENCE CONTINUED:

Employer Address City, State, Zip Job Title Supervisor Reason for Leaving Dates Employed: Hourly Rate/Salary: Employer Address City, State, Zip Job Title Supervisor Reason for Leaving Dates Employed: Hourly Rate/Salary: May we contact this employer for references? May we contact this employer for references? Duties Performed: Duties Performed:

Please use additional pages if needed.

Galloway Company
Employment Application F-HR-004-C Please answer the following questions: Are you 18 years old or over? Are you currently employed? Page 5 of 9 9/18/2012
This document contains trade secret/confidential commercial information pursuant to 5 U.S.C 552(b)(4)

YES YES

NO NO NO NO

Are you on layoff, subject to YES recall? Have you ever been discharged from any position? If yes, state facts & penalty. Have you been convicted of a felony? If yes, state facts & penalty. Do you have friends or family who work for Galloway Company?

NO

NO If yes, please name employee and state relationship. Are you legally eligible for employment in this country? Are you able to meet the attendance requirements for the position? Will you work overtime if required? Have you ever been employed at Galloway Company before? Date available for work? YES YES YES YES NO NO NO NO

NOTICE: Some of the positions at Galloway Company are filled using various selection tests. If the position for which you have applied is filled utilizing selection test, you will receive notice of the time, date, and place. If you require special accommodation, please contact the Personnel Office at (920) 722-7741 at least (7) days prior to the test.

Galloway Company
Employment Application F-HR-004-C Page 6 of 9 9/18/2012
This document contains trade secret/confidential commercial information pursuant to 5 U.S.C 552(b)(4)

Galloway Company Voluntary Affirmative Action Information

Galloway Company is required by State and Federal employment regulations to keep records and make reports to the Equal Employment Opportunity Commission. By answering the questions below, you will assist us in our reporting requirements. The information is voluntary and will be collected and used for statistical purposes only. This form will be filed separately from your application and will not be used to discriminate in any way in the employment process. Name: Male / Female Date: Position applying for: ETHIC ORIGIN: Please circle one White American Indian /Alaskan Native

Hispanic

Black

Asian/ Pacific Islander

SPECIAL NOTICE TO VIETNAM ERA VETERANS, DISABLED VETERANS, AND INDIVIDUALS WITH PHYSICAL OR MENTAL DISABILITIES: Government contractors subject to Vietnam Era Veterans Readjustment Act of 1974 and the Rehabilitation Act of 1973 are required to take affirmative action to employ and advance in employment qualified disabled veterans and veterans of the Vietnam Era, and qualified handicapped individuals. You are invited to volunteer this information, if you qualify, to assist in proper placement and determining reasonable accommodation. This information will be considered confidential, and refusal to provide this information will not adversely affect your consideration for employment. IF YOU WISH TO BE IDENTIFIED, PLEASE CIRCLE IF ANY OF THE FOLLOWING ARE APPLICABLE: VIETNAM VETERAN DISABLED VETERAN HANDICAPPED INDIVIDUAL How did you hear about the job in which you are applying? Please circle all that apply. Employee or Relative School Employment Agency Advertisement Other ( Please Explain)__________________________________________________ ____________________________________________________________________
This form is to be completed by applicant - Not for interview purposes - to be filed separately from application. This information is used to satisfy the Affirmative Action requirements of Section 503 of the Rehabilitation Act or necessitated by another federal law or regulation.

Galloway Company
Employment Application F-HR-004-C Please list any additional information you would like us to consider: Page 7 of 9 9/18/2012
This document contains trade secret/confidential commercial information pursuant to 5 U.S.C 552(b)(4)

It is understood and agreed upon that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or discharge from the Galloway Companys service if I have been employed. Furthermore, I understand that just as I am free to resign at any time, Galloway Company reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of Galloway Company has the authority to make any assurances to the contrary. I give the Galloway Company the right to investigate all references and to secure additional information about me, if job related. I hereby release from liability the Galloway Company and its representatives for seeking such information and all other persons, corporations, or organizations for furnishing such information. Galloway Company is an Equal Opportunity Employer. Galloway Company does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicants consideration for employment on a basis prohibited by local, state or federal law. This application is current for (1) year. At the conclusion of that time, if I have not heard from the Galloway Company and still wish to be considered for any reported openings, it will be necessary to fill out a new application.

____________________________________ Signature of Applicant

____________________________ Date

Galloway Company
Employment Application F-HR-004-C Situation Questions 1. Describe a situation where you had to make a decision but you did not have all the information you needed. Page 8 of 9 9/18/2012
This document contains trade secret/confidential commercial information pursuant to 5 U.S.C 552(b)(4)

2. Describe a situation where you found an error in your work. What was the cause? How was it handled?

3. Give an example of a time when you were given a task to accomplish without advance warning.

4. Give a specific example of doing more than required in one of your previous jobs.

5. Describe a situation where you wished you had acted differently with someone at work. What did you do? What happened as a result?

6. Describe a time when you organized your thoughts on a matter of importance to you, and in communicating these to others; you felt you got you points across well.

Galloway Company
Employment Application F-HR-004-C Page 9 of 9 9/18/2012
This document contains trade secret/confidential commercial information pursuant to 5 U.S.C 552(b)(4)

7. Describe a time when you brought together a group of people to work with each other in some activity or project?

8. Describe a time when you set your sights on a high, demanding goal and achieved it.

9. Give an example of a new idea that you came up with that made a significant contribution to the success of some activity or project.

10. Give an example of an experience where you came to be regarded by other people as a person who could be trusted to listen to them and treat them fairly.

11. Give examples of your involvement in safety and wellness programs at your previous positions.

___________________________________ Print Name

____________________________________ Signature