Rockland Manufacturing Company

Company Information

Required fields are marked with an * .

Applicant Information

Yes No

Yes No

Yes No

Convictions will not automatically bar you from being considered for employment.


Yes No

Yes No

Yes No


Please list three professional references.

Employment History

Yes No

Yes No

Yes No

Military Service

Equal Opportunity Employer

Rockland Manufacturing Company is an Equal Opportunity Employer. As required by law, we must record certain information to be made a part of our Affirmative Action Program.

Applicants for employment are also invited to participate in the Affirmative Action Program by reporting their statusas disabled, disabled veteran, veteran of the Vietnam era or other minority. In extending this invitation you are also advised that:(a) workers (applicants) are under no obligation to respond, but may do so in the future if they choose; (b) responses will remain confidential within the Human Resources Department; and (c) responses will be used only for the necessary information to include in our Affirmative Action Program. We are a company that values diversity. We actively encourage women and minorities to apply. Refusal to provide this information will have no bearing on your application and will not subject you to any adverse treatment.

Please complete the information requested below. Thank you for your cooperation.

Section 1: General Applicant Information

Section 2: Please check (4) all that apply

Race or Ethnic Identity

Hispanic or Latino
Black or African American
Native Hawaiian or Pacific Islander
American Indian or Alaskan Native
Two or More Races
I do no wish to Self-Identify.


Male Female

**Veteran Status

Vietnam Era Veteran
Special Disabled Veteran
Other Protected Veteran
Recently Separated Veteran
Armed Forces Service Medal Veterans


Individual with Disabilities

How did you hear of our opening?

Current Employee
Newspaper Ad
Other: Explain Below


I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Any offer of employment is contingent upon satisfactory results of a pre-employment drug screen and criminal background check.

© 2012-2018 Rockland Manufacturing Company