APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT
612W Main St Unit 2, Tilton NH 03276

Phone: 603-286-7657 Fax: 603-286-7882 Email:info@gototsi.com

TSI is an equal opportunity employer and all information provided on this form will be kept in the strictest confidence. Certain information (POB, DOB, SSN, Convictions, etc) is required for US Security Clearance purposes only. Thank you for your interest in working with Tri-State Painting, LLC (TSI), please review all attached policies and procedures before proceeding with this application.

Once Complete please upload/email the following documents over.

Driver’s License
Social Security Card
Passport / Naturalization Certificate
Any/all certifications you currently carry. Nothing expired should be submitted.
A copy of a VOIDED Check or Bank print out verifying Direct Deposit Information.
Tax forms: W-4, I-9, Mass M-4 Form, Maine W-4, as well as your home state tax form.
PERSONAL INFORMATION
NAME:
Name

First NameMiddle NameLast Name
PHYSICAL ADDRESS:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different):
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CELL PHONE NO:
Phone Number
Please enter a valid phone number.
EMAIL ADDRESS:
example@example.com
PLACE OF BIRTH:
SOCIAL SECURITY NUMBER:
DATE OF BIRTH:
UNITED STATES CITIZEN?

YesNo
If No List Country of Citizenship
Voluntary ID for Affirmative Action

It is the policy of Tri-State Painting, LLC to take affirmative action to assure that applicants are employed and that employees are treated during employment without regard to race, color, sex, age, religion, national origin or status as a veteran. Such action shall include employment, upgrading, demotion or transfer, recruitment or recruitment advertising, layoff or termination, rates of pay or other forms of compensation and selection for training.We are required to provide statistical information to the gender and ethnicity of applicants andemployees to the various government agencies for which we work. To help us comply with theserequirements we ask that you complete this Voluntary Identification for Affirmative Action Purposesform.This information will be used only to comply with those governmental requirements. It will bemaintained in the corporate office, separately from the Application for Employment. It will in no wayaffect your employment.Your participation is voluntary. Your decision to participate or not will have no impact on your status.
Gender

FemaleMalePrefer not to say
Race

WhiteBlack/African AmericanAmerican IndianAsian or IndianOther
Decline to Participate

Decline
Medical Result Authorization
By checking this box, I hereby authorize TSI to release the results of all pre-employment/follow up medical tests, to include: Drug Screen, Audiogram, Blood Leads, and PFTs to General Contractors as necessary per Job specific requirements.

I agree
State Paid Leave Acknowledgment
By checking below boxes, I acknowledge receipt of State Paid Leave Program information and understand the contribution amounts that will be deducted by Payroll when I wook on projects in the following states, or if I have a permanent residence in said state

Massachusetts Paid Family and Medical Leave NoticeConnecticut Paid Leave Notice
HAVE YOU EVER BEEN CONVICTED OF A FELONY?
NoYes
If Yes Please Explain:
UNION AFFLIATION:
ARE YOU CURRENTLY A UNION MEMBER?

NoYes
(IF YES) DC#
CURRENT UNION LEVEL

JOURNEYMANAPPRENTICEOther
EDUCATION
LIST HIGHEST LEVEL COMPLETED (GED, HS, College, etc):

LIST SPECIAL SKILLS / CERTIFICATIONS : (C3,C5,C7,QC, NACE, etc):

*Please Provide copies of all certifications listed.
MILITARY SERVICE
YesNo
Branch
Rank
Discharge
CURRENT MEMBER GUARD OR RESERVES

YesNo
If Yes State:
EMPLOYMENT DESIRED
Position:
Date Available to Start:
Are you currently employed?

YesNo
Current Employer:
How Long Were You Employed?
Have you ever worked for TSI before?

YesNo
If Yes, When?
EMPLOYMENT HISTORY
FORMER EMPLOYERS:
PHYSICAL RECORD
Do you have any physical limitations that prevent you from performing any work for which you are being considered?

NoYes
If yes, please explain:
Emergency Contact
I certify that the facts contained in this application are true and complete to the best of my knowledge and I understand that if employed, falsified statements on this application shall be grounds for dismissal.
I authorize investigation of all statements contained herein and the references 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 all parties from all liability for any damage that may result from furnishing same to you.
I understand and agree that, if hired, 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 prior notice.
Direct Deposit Information
Name of Financial Institution:
Type of Account

CheckingSavings
Routing Number
Account Number
Opt out of Direct Deposit

Refuse Direct Deposit and Receive a paper check at mailing address listed above
File Upload (Certs and licenses)

Cancelof
Signature

Clear
Date:
P. O. Box 1240 Tilton, NH 03276

Phone: 603-286-7657 Fax: 603-286-7882 www.GoToTSI.com
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APPLICATION FOR EMPLOYMENT

PERSONAL INFORMATION

NAME:

PHYSICAL ADDRESS:

CELL PHONE NO:

EMAIL ADDRESS:

PLACE OF BIRTH:

SOCIAL SECURITY NUMBER:

DATE OF BIRTH:

Voluntary ID for Affirmative Action

Medical Result Authorization

State Paid Leave Acknowledgment

HAVE YOU EVER BEEN CONVICTED OF A FELONY?

UNION AFFLIATION:

EDUCATION

MILITARY SERVICE

EMPLOYMENT DESIRED

EMPLOYMENT HISTORY

FORMER EMPLOYERS:

PHYSICAL RECORD

Direct Deposit Information