PCI Paving Employment App

Today's Date

Date

Position Applying for:

How soon could you report to work?

Enter the first day you could start

Name*

First NameLast Name

Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email Address

example@example.com

Are you over the age of 18? If no, employment is subject to verification that you are of minimum age.*

YesNo

Are you a citizen of the United States?*

YesNo

Are you authorized to work in the United States on an unrestricted basis?*

YesNo

Do you have a valid Kansas Driver's License?*

YesNo

Driver's License Number:

Do you have a good driving record?*

YesNo

Have you ever been convicted of a crime, except for a minor traffic violation?*

YesNo

If yes, state the date, location, and nature of the crime:

Do you have a high school diploma or GED?*

YesNo

High School Education:

College Education:

List any special skills/experience that you feel would help you in the position you are applying for (i.e. asphalt or concrete knowledge, equipment operation, leadership skills, etc.)

Have you ever applied for a job with us before?*

YesNo

Have you ever worked for us before?*

YesNo

Have you ever been discharged or requested to resign from a position?*

YesNo

If yes, please explain:

Does your current employer know you plan a change of employment?*

YesNoNot currently employed

May we contact them?*

YesNo

Why do you desire to make a change?

Have you ever help a position of trust? (i.e. handling money or confidential material?)*

YesNo

How much time have you lost from work in the past year?*

Current or most recent Employer:

Previous Employer:

References*

Applicant Agreement and Certification

“I certify that the information given by me in this application is true in all aspects and I agree that if employed and it is found to be false in any way, that I may be subject to dismissal without prior notice. I authorize the use of any information in this application to verify my statements and I authorize the past employers and all references to answer all questions asked concerning my ability, character, reputation and previous employment record. I further agree, if employed, that I am to work faithfully and diligently. I will be careful to avoid accidents, to come to work promptly and will not be absent for any reason without prior notice to my supervisor. And that employment is terminable at the will of either employee or employer. I agree to be employed for a probationary period of 30 calendar days and that I may be dismissed at any time during this period at the discretion of the employer. I agree to submit to a physical examination and a drug screening whenever requested. And if employed, I agree to observe and adhere to all personnel policies and rules. I understand this is not a contract of employment and I do not construe it as such.”

Signature

Date

Employment Application Form

Personal Information

Education

Special Skills

Employment History

Prior Work History