Flagger Job Application Form

Full Name*

First NameMiddle NameLast Name

Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Email Address*

Phone Number*

Area CodePhone Number

Have you applied with this company before, if so, what position?*

Available to Start Date*

MonthDayYear

Salary Desired?*

Are you employed now?*

YesNo

May we contact your current employer?*

YesNo

Indicate Level of Education*

	Completed	Did Not Complete
High School or GED
College
Trade or Tech School

Do you have any special license or training?

Hobbies or Interests?

Upload Flagger Card (Required for this position)*

Upload a File

Must be valid flagger card in Washington State

Do you have a valid Driver License?*

YesNo

Are you willing to take a complete physical examination?*

YesNo

Are you willing to complete a drive record request form? (Required for employment)*

YesNo

Are you willing to complete a UA? (Required for employment)*

YesNo

Employment History*

	Start & Quit Date	Company Name	Employer Phone number	Salary	Reason for Leaving
1.)
2.)
3.)
4.)

References*

	Name	Phone Number	Relationship	Business	Years Acquainted
1.)
2.)
3.)

Please review the Job Description - Acceptance of Physical Ability to Perform Duties below:

We utilize an aggressive return to work policy which provides light duty and modified work in the event of an on the job injury or illness. I have read the Job Description - Acceptance of Physical Ability to Perform Duties. By signing below, I confirm my physical ability and willingness to perform all duties required as a flagger.

Furthermore, I acknowledge that I have read and completely filled out the above listed employment application. I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts called for is cause for dismissal. I understand and agree that my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without any previous notice. Further, I understand that any testing and orientation is a part of my pre-employment qualification and I will not be compensated for this time. I also authorize the release of my medical records to Henifin Construction, LLC, & Safety Signs Inc.

Upon termination, layoff, or voluntary quit from the company, I understand that I am to complete a separation questionnaire prior to issuance of a final check.

** Note ~ All Applications are discarded after 60 days **

Signature