U.S. EMPLOYMENT PPLICTION ppliedmicro Is n Equal Opportunity pplicants are considered for all positions without regard to race, color, religion, sex, national origin, ancestry, age, marital status or veteran status, sexual orientation, medical condition or the presence of a physical or mental disability, which can be reasonably accommodated, or any other category protected by law. NME & DDRESS First Middle Last Phone Home Number & Street (pt.) Phone Work City State Zip Phone Cellular E-Mail ddress Position pplying for: Which Location: Requisition Number: Date vailable: How did you learn about us? dvertisement Employment gency Internet/E-mail Other Employee Referral by: Job Fair Walk-in re you employed now? If yes, may we contact your present employer? If necessary, best time to call you at home: am pm If you are under 18 years of age, can you provide required proof of your eligibility to work? Do you have any records, degrees, etc. listed under any other name? If yes, please indicate name(s): GENERL INFORMTION Have you filed an application, interviewed, or been employed with us before? If yes, give date: Do you have any relatives who are currently employed by ppliedmicro? If yes, please indicate name(s): If hired in the United States, can you provide proof that you are a citizen or national of the United States, a lawful permanent resident, or an alien authorized to work in the U.S.? Have you ever been convicted of a criminal offense? (Conviction of a crime will not necessarily constitute an absolute bar to employment.) If YES, state the nature of the crime(s), when and where convicted and disposition of the case. (te: Consideration for employment may include the nature of any criminal offense conviction, the date of the offense, the surrounding circumstances, and the relevance of the offense to the position(s) applied for.) re you currently out on bail or on your own recognizance pending trail for a prior arrest? FOR CLIFORNI PPLICNTS ONLY: In answering the two questions above, you should omit any information concerning (a) any arrest or detention that did not result in conviction; (b) any conviction for which the record has been judicially ordered sealed, expunged, or statutorily eradicated; (c) any misdemeanor conviction for which probation has been successfully completed or otherwise discharged and the case has been judicially dismissed pursuant to Penal Code section 1203.4; (d) any arrest for which a pretrial diversion program has been successfully completed pursuant to Penal Code sections 1000.5 and 1001.5; and (e) a conviction that is more than two years old for marijuana-related offenses under sections 11357(b), 11357(c), 11364(c), 11364, 11365, or 11550 of the California Health and Safety Code. If hired, can you perform the essential functions of the job for which you are applying with or without a reasonable accommodation of a mental or physical disability? Doc.. 4107017 Rev. 1 Page 1 of 5
Type of Name of City/State Check in Highest Year Completed 1 2 3 4 Year Grad Grade Point Degree Major Minor High EDUCTION College Other or usiness/ Trade re you a continuing student? If yes, where? Program? dditional job-related educational and/or vocational or technical training information: Patents, Publications, Honors: HONORS Employment Experience Instructions Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations, which indicate race, color, religion, gender, national origin, handicap, or other protected status under the applicable local, state, and federal law. Please complete all areas regardless of resume. ddress EMPLOYMENT EXPERIENCE Doc.. 4107017 Rev. 1 Page 2 of 5
ddress ddress DDITIONL EMPLOYMENT EXPERIENCE ddress. ttached additional information as required. Doc.. 4107017 Rev. 1 Page 3 of 5
PPLIEDMICRO PPLICNT SURVEY pplied Micro Circuits Corporation is an ffirmative ction, Equal Opportunity. We must demonstrate that we meet Equal Employment Opportunity requirements by reporting statistical information to the federal government about applications for employment. The confidential information requested is necessary for our reporting requirements. This information will be kept separate from other employment papers and will not be used in any way to make employment decisions; it simply helps us keep our records accurate- Your participation is voluntary and would be greatly appreciated. Name: Date: Position pplying for: PLESE CHECK THE FOLLOWING PPLICLE OXES: VETERN OF THE VIETNM ER - (ctive duty of more than 180 days, any part of which occurred between ugust 5, 1964 and May 7, 1975 with a release or discharge other than dishonorable. NOTE: YOU RE ONLY COVERED UNDER THIS PROGRM FOR 45 MONTHS FOLLOWING YOUR DISCHRGE OR RELESE FROM MILITRY SERVICE). U.S. Military Service From: To: DISLED VETERN (ny person entitled to disability compensation under laws administered by the Veterans dministration for disability rated at 30 percent or more, or a person whose discharge or release from active duty was for a disability incurred or aggravated in the line of duty). DISLED (ny person who has a physical or menial disability, which substantially limits one or more of such person's major life activities, has a record of such impairment, or is regarded as having such impairment). PPLICNT SURVEY ny information provided regarding a disability shall be kept confidential in accordance with the requirements under the mericans with Disabilities ct. OTHER ELIGILE VETERN RCE OR ETHNIC GROUP: Hispanic or Latino person of Cuban, Mexican, Puerto Rican, South or Central merican, or other Spanish culture or origin regardless of race. White (t Hispanic or Latino) person having origins in any of the original peoples of Europe, the Middle East, or rth frica. lack or frican merican (t Hispanic or Latino) person having origins in any of the peoples of the black racial groups of frica. Native Hawaiian or Other Pacific Islander (t Hispanic or Latino) person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands. sian (t Hispanic or Latino) person having origins in any of the peoples of the Far East, Southeast sia, or the Indian Subcontinent, including for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. merican Indian or laska Native (t Hispanic or Latino) person having origins any of the original peoples of rth and South merica (including Central merica), and who maintains a tribal affiliation or community attachment. Two or More Races (t Hispanic or Latino) ll persons who identify with more than one of the above six races. Doc.. 4107017 Rev. 1 Page 4 of 5
REFERENCES Please list three professional references. Include at least TWO previous or ONE current supervisor and one work peer. Do not include relatives. NME THT PPLIEDMICRO MY CONTCT PULIC RECORDS WIVER: YERS RELTIONSHIP OCCUPTION/ PHONE OK TO CONTCT? KNOWN TO PPLICNT COMPNY E-MIL YES NO RELESE The following must be signed. I understand that ppliedmicro may obtain certain public records containing information about me during the course of its consideration of my application for employment. Please select one: I waive my right to receive a copy of any public records containing information about me. I do not waive my right to receive a copy of any public records containing information about me. I hereby certify that the answers given by me to the foregoing questions and statements are true and correct, without mental reservations of any kind. I understand that misrepresentation or omission of facts called for in this application, interview(s), or any component of the hiring process is cause for refusal to employ and for dismissal at any time during the period of my employment. I authorize investigation of all statements contained in this application through the above mentioned companies, schools or persons or their agents (present employer will be contacted only when specific permission is granted or after acceptance of offer). I hereby release said companies, schools, or persons from all liability for any damage for issuing this information. I understand that after the point of hire, but before beginning employment, I will be required to submit proof of any legal right to work in the country in which I am applying for employment and to sign an agreement relating to the protection of trade secrets and assignments of inventions to the Company. If hired, I understand I will be required to abide by all rules and regulations of the Company. In consideration of my employment, I acknowledge and agree that my employment may be terminated, with or without cause, and with or without advance notice, at any time at the option of either the Company or myself. I understand that no supervisor or representative of the Company other than the President has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing. In addition, any such agreement by the President must be in writing. Date: Signature: Doc.. 4107017 Rev. 1 Page 5 of 5