JOB APPLICATION

John Piccirilli, Inc. 1019 Conklin Rd, Conklin, New York 13748 (607)775-1316

John Piccirilli, Inc. is an equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Should an applicant need reasonable accommodation in the application process, he or she should contact a company representative.

Please fill out all of the sections below:

Applicant Information Applicant Name:

Do you have previous experience in the Plumbing and HVAC field?*

YesNo

Applicant Name*

Address*

Address

Street Address Line 2

City, State and Zip Code

Telephone Number*

Email Address*

example@example.com

Date of Application*

Date

Employment Position Position(s) applying for: Plumbing/HVAC Technician ( full time)

How did you hear about this position?*

What days are you available for work?*

What hours or shift are you available for work?*

If needed, are you available to work overtime?*

On what date can you start working if you are hired?*

Date

Do you have reliable transportation to and from work?*

Salary desired*

Have you ever applied to or worked for John Piccirilli, Inc. before?

If yes, when?*

If yes, state name & relationship*

Do you have any friends, relatives, or acquaintances working for John Piccirilli, Inc. If yes, state name & relationship:

Are you 18 years of age or older? Are you a U.S. citizen or approved to work in the United States?

What document can you provide as proof of citizenship or legal status?*

Will you consent to a mandatory controlled substance test? Do you have any condition which would require job accommodations?

If yes, please describe accommodations required below.*

Have you ever been convicted of a criminal offense (felony or misdemeanor)?

If yes, please state the nature of the crime(s), when and where convicted and disposition of the case*

(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered

Job Skills/Qualifications Please list below the skills and qualifications you possess for the position for which you are applying:

(Note: John Piccirilli, Inc. complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. )

Education and Training High School Name

Name*

Location (City, State)*

Year Graduated*

Degree Earned*

Name*

Location (City, State)*

Year Graduated*

Degree Earned*

Vocational School/Specialized Training Name

Name*

Location (City, State)*

Year Graduated*

Degree Earned*

What branch of the military did you enlist?*

Are you a member of the Armed Services?*

What was your military rank when discharged?*

How many years did you serve in the military?*

What military skills do you possess that would be an asset for this position?*

Previous Employment Employer Name: Job Title:

Job Title*

Employer Name*

Supervisor Name: Employer Address: City, State and Zip Code: Employer Telephone: Dates Employed: Reason for leaving*

City, State and Zip Code*

Employer Address*

Supervisor Name*

Dates Employed*

Date

Reason for leaving*

Employer Name*

Supervisor Name: Employer Address: City, State and Zip Code: Employer Telephone*

Job Title*

Employer Address*

Supervisor Name*

City, State and Zip Code*

Dates Employed: Reason for leaving:

Dates Employed*

Date

Reason for leaving*

Employer Name*

Job Title*

Employer Address: City, State and Zip Code: Employer Telephone: Dates Employed: Reason for leaving*

Address*

Employer Address

Street Address Line 2

City, State and Zip Code

Supervisor Name*

Dates Employed*

Date

Reason for leaving*

References Please provide 3 personal and professional reference(s) below:

Reference 1*

Reference 2*

Reference 3*

Do you have any licenses and/or certifications that would assist you in the job? (i.e. EPA, Well Pumps, etc)*

The relationship between you and the John Piccirilli, Inc. is referred to as "employment at will." This means that your employment can be terminated at any time for any reason, with or without cause, with or without notice, by you or the John Piccirilli, Inc No representative of John Piccirilli, Inc. has authority to enter into any agreement contrary to the foregoing "employment at will" relationship. You understand that your employment is "at will," and that you acknowledge that no oral or written statements or representations regarding your employment can alter your at-will employment status, except for a written statement signed by you and either our Executive Vice-President/Chief Operations Officer or the Company's President.

Applicant Signature

Dated

Date