APPLICATION FOR EMPLOYMENT 3868 Congress Parkway Richfield, OH 44286 http://www.ccgautomation.com

Name Last First Middle Present Address Street City Zip Phone Numbers/E-mail Home Cell Email Permanent Address(If Different from Above) Street City Zip

Position Desired: Expected Salary: Date Available: Are you related to anyone currently working at CCG Automation, Inc.?   Yes      No If so, who? Have you ever applied for work at CCG Automation, Inc. before?   Yes      No If so, when? How did you hear about this position? Type of Employment   Full Time      Part Time Are you 18 years of age or older?   Yes      No

Level: Name/Location: Did You Graduate? Degree: Major Areas: GPA: High School / G.E.D.   Yes College / University   Yes Technical School   Yes

In applying for employment, it is understood that we reserve the privilege of contacting past employers regarding references.
May we also contact your present employer?   Yes

Please list most recent employment first.

Company Address Business Telephone Number From (Mo/Yr) - To (Mo/Yr) Present Title Supervisors Name & Title Starting Salary Last Salary Reason For Leaving Duties and Responsibilities Company Address Business Telephone Number From (Mo/Yr) - To (Mo/Yr) Present Title Supervisors Name & Title Starting Salary Last Salary Reason For Leaving Duties and Responsibilities Company Address Business Telephone Number From (Mo/Yr) - To (Mo/Yr) Present Title Supervisors Name & Title Starting Salary Last Salary Reason For Leaving Duties and Responsibilities Company Address Business Telephone Number From (Mo/Yr) - To (Mo/Yr) Present Title Supervisors Name & Title Starting Salary Last Salary Reason For Leaving Duties and Responsibilities

Have you ever been a member of the armed forces of the Unites States?   Yes      No If so, describe any special skills or abilities you developed which relate to the job you are seeking: Can you submit proof of U.S. Citizenship?   Yes      No If no, explain. Note : If hired, you will be required to furnish proof of U.S. Citizenship or your authorization to work in the U.S. as specified under applicable U.S. Immigrations Laws. Have you ever been convicted under your current name or any other (i) of a felony or (ii) within the past five years of a misdemeanor which resulted in imprisonment? (Note: conviction is not necessarily a bar to employment.)   Yes      No If yes, give date, court, nature of offense, and disposition Date Court Nature of Offense Disposition

PLEASE PROVIDE ANY ADDITIONAL INFORMATION RELATIVE TO THE FOLLOWING QUESTIONS: Describe the work you expect to be assigned if hired by CCG Automation, Inc.: Tell us what specific qualities or attributes you might add to CCG Automation, Inc.: State any information that might be helpful in considering this application that is not apparent elsewhere:

Name / Address: Phone: How Acquainted / How Long Business / Title

By submitting this form, you are agreeing to the following:

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be ground for dismissal.

I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise and release the company from all liability for any damage that may result from utilization of such information.

I understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature. I also understand and agree that no representative of the company 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, unless it is in writing and signed by an authorized company representative.”

CCG Automation, Inc. is a smoke free employer. Smoking and/or the use of tobacco products are not permitted within the company facilities, on company grounds, in company owned vehicles, or at client job sites.

CCG Automation, Inc. is a drug-free company. All new hires are subject to pre-placement drug screen and background check.