NAME
Name
*
First Name
Last Name
Have you ever been known by or used another name (e.g. married or maiden name, etc.), specify name and date:
*
Are you 21 Years or Older?
Yes
No
Social Security No.
*
PRESENT ADDRESS
Street Address
*
City
*
State
*
Zip Code
*
Phone Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
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Position
Position you are applying for:
*
Please Select
Laborer
Equipment Operator
Foreman
Driver
Superintendent
Administrative
Management
Other
Type of Employment Desired:
Please Select
Regular
Temporary
Part Time
Summer
Description of Desired Position
Date Available for Work
*
-
Month
-
Day
Year
Date
Minimum Salary Requirement
Have you ever applied for work or been employed by this company?
*
Yes
NO
If yes, location and approximate date:
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EMPLOYMENT HISTORY
Please tell us about your most recent employment history and/or relevant job experience.
Most Recent Employer
Company Name
*
Phone Number
*
Street Address
*
City
*
State/ Province/ Region
*
Zip/ Postal Code
*
Country
*
Employed From
*
-
Month
-
Day
Year
To
*
-
Month
-
Day
Year
Name and Title of Supervisor
*
Starting Salary
Ending Salary
Position and Responsibilities
Reason for Leaving
Second Most Recent Employer
Company Name
Phone Number
Street Address
City
State / Province / Region
ZIP / Postal Code
Country
Employed From
-
Month
-
Day
Year
To
-
Month
-
Day
Year
Name and Title of Supervisor
Starting Salary
Ending Salary
Position and Responsibilities
Reason for Leaving
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REFERENCES
Please List References Not Employed by This Company
Name
Address
Phone Number
BACKGROUND
Have you ever been convicted of a criminal offense?
*
Yes
No
If yes, please explain:
If hired, would you be able to present evidence of your US citizenship or proof of your legal right to work in the U.S.?
*
Yes
No
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DOT / PRE-EMPLOYMENT
Do you have a driver's license at present?
*
Yes
No
License State
*
License Type
*
Please Select
Regular
CDL
Driver's License No.
*
Expiration Date
*
-
Month
-
Day
Year
Birth Date
*
-
Month
-
Day
Year
Have you been involved in any motor vehicle accidents while driving in the last three years?
*
Yes
No
If yes, explain.
List all prior convictions for driving while intoxicated, reckless driving or possession of non-prescription drugs.
*
List all violations of motor vehicle laws or ordinances for which you were convicted in the last three years (excluding parking violations)
*
Have you ever had a license, permit or privilege to operate a motor vehicle suspended, revoked or denied?
*
Yes
No
If yes, explain.
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AUTHORIZATION FOR THE RELEASE OF PERSONAL DATA AND RECORD INFORMATION
As a condition of my employment with the Company, I understand that I must undergo and pass, the Company's satisfaction, a thorough background investigation and post-hire physical examination, including a drug/alcohol screen. I hereby authorize and request that any of the information listed below be provided to the Company. A photocopy of this authorization may be treated with the same authority as the original. This certified that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.
Signature
*
Date
*
-
Month
-
Day
Year
In connection with my application for employment for you, I understand that a consumer report on me will be requested and used for the purpose of evaluating me for employment. In additional, if I am hired, I understand that future consumer reports may be requested and used for purposes of evaluating me for promotion, reassignment or retention as an employee. I hereby consent to you obtaining such report(s).
Signature
*
Date
*
-
Month
-
Day
Year
ACKNOWLEDGEMENTS
Please read and initial each of the following:
I certify that all statements I have made in this application are true and agree that any misrepresentation or omission of facts requested may be sufficient cause for cancellation of my application or immediate dismissal from the Company if I have been employed. In the event that I am employed, I agree to conform to the rules and policies of the Company. I understand that these rules and policies may be changed, interpreted, withdrawn, or added to at the Company's option at any time without notice.
*
Acknowledge
I understand that employment is contingent upon meeting the physical requirements of the job and passing, to the Company's satisfaction, a drug screen. Depending upon the nature of the job for which I am applying, I understand that the satisfactory completion of post-hire physical examination may also be required.
*
Acknowledge
I acknowledge the Company's notification to me that a background investigation or an investigative consumer report on me may be made. I understand and agree that successful completion to the Company's satisfaction of such investigation(s) is required for employment or continued employment. I hereby authorize the Company to conduce or have conducted the investigation(s) described above and to prepare or cause to be prepared a report based on such information. I further understand that, upon my written request, a complete disclosure of the nature and scope of the investigation(s) conducted will be provided to me.
*
Acknowledge
I agree that the Company's liability to me for wages is limited to the amount earned by me as of the date of such termination. I also authorize the Company to deduct at any time any monies owed by me to the Company whenever such deduction is not prohibited by law.
*
Acknowledge
I understand that federal law prohibits the employment of unauthorized aliens and that all persons hired must submit satisfactory proof of employment authorization and identity generally within three days of being hired. I further understand that the failure to submit such proof within the required time will result in immediate dismissal from the Company if I have been employed.
*
Acknowledge
I understand that my disclosure of prior convictions for criminal or traffic offenses will not necessarily prevent my employment with the Company; however, the omission of this requested information will be sufficient cause for cancellation of my application or my immediate dismissal from the Company.
*
Acknowledge
I have read and agree to the above acknowledgements.
*
Acknowledge
Signature
*
Date
*
-
Month
-
Day
Year
Submit
Should be Empty: