Careers &#8211; Zack Burkett Co.

General Information

Full Name*

Social Security No.*

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Permanent Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Referred by:*

YesNo

Location:*

Job applying for:*

YesNo

Driver's License No.

State

Type

Expiration Date

Date

(Applicants seeking employment as a commercial truck driver complete DOT application)

Education & Experience

Highest level of education completed*

Last school attended*

City & State*

List any courses, training, and skills

Employment History

YesNo

If not, how long since last employment?

Current Employer

Contact Person

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Type of Work

Dates Worked

Reason for Leaving

Employer (2)

Contact Person

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Type of Work

Dates Worked

Reason for Leaving

Employer (3)

Contact Person

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Type of Work

Dates Worked

Reason for Leaving

YesNo

When?

Location

Supervisor

Reason for leaving

List all relatives working for Zack Burkett Co.

YesNo

Is there any reason you might be unable to perform the functions for the job for which you have applied?*

Zack Burkett Co. Contraband Policy for Employees and Employment Applicants

***IMPORTANT***
READ THE FOLLOWING ZACK BUBKETT CO, CONTRABAND POLICY AND AUTHORIZATION AND CONSENT; THEN SIGN AND DATE THE APPLICATION INDICATING YOU UNDERSTAND AND AGREE TO ABIDE BY THESE PROCEDURES AND CONDITIONS.

For the purpose of this policy, contraband includes, but is not limited to, marijuana, illegal drugs, drug paraphernalia, controlled substances, mind-altering substances, unauthorized prescription drugs, firearms, ammunition, weapons, unauthorized explosives. stolen property and alcoholic beverages.

STATEMENT OF POLICY
Contraband possession, use, or distribution by any person, or the presence of marijuana, illegal drugs, controlled substances, mind-altering substances, unauthorized prescription drugs, or alcohol in a person's bodily system while on any Zack Burkett Co. property, work location or other facility, adversely affects work operations and poses a serious threat to the safety of Zack Burkett Co. employees and sub-contractors. In order to assist in maintaining a safe working environment for its employees, contraband possession, use or distribution, or the presence of marijuana, illegal drugs, controlled substances, mind-altering substances, unauthorized prescription drugs, or alcohol in a person's bodily system is not permitted on any Zack Burkett Co. property, work location or other facility.

SEARCHES, INSPECTIONS AND ANALYSES
As a part of its efforts to maintain a safe working environment for its employees and subcontractors, Zack Burkett Co. reserves the right at all times to have medical personnel conduct or supervise urinalysis and/or blood tests of Zack Burkett Co. employees for the purpose of determining if any such persons have the presence of marijuana, illegal drugs, controlled substances, mind-altering substances, unauthorized prescription drugs, or alcohol in their bodily system. Urinalysis and/or blood tests are required at the time of a pre-employment physical and may be required when an employee is treated at a medical facility for an injury related to employment with Zack Burkett Co. or from time to time without prior announcement.

Any Zack Burkett Co. employee who misrepresents facts during urinalysis and/or blood tests or tampers with a urine or blood sample will be immediately suspended from work without pay pending disciplinary action, which may result in discharge from employment. Any Zack Burkett Co. employee who refuses to submit to a search, inspection, urinalysis and/or blood test, or who is found to be possessing or distributing contraband, or who has the presence of marijuana, illegal drugs, controlled substances, mind-altering substances, unauthorized prescription drugs, or alcohol in his/her bodily system without an explanation satisfactory to Zack Burkett Co. will be immediately suspended from work without pay pending disciplinary action, which may result in discharge from employment.

Any employment applicant who refuses to submit to a pre-employment physical, urinalysis and/or blood test will not be accepted for employment by Zack Burkett Co.

Any contraband discovered through searches or inspections performed by authorized personnel of Zack Burkett Co. will be taken into custody and will be turned over to the proper law enforcement authorities.

Entry into Zack Burkett Co. property, work locations or other facilities constitutes consent to and recognition of the right of Zack Burkett Co. to have its authorized personnel conduct searches and/or inspections of all persons, their personal effects, lockers, baggage, vehicles and living quarters located thereon for the purpose of determining if any such persons are in possession of contraband. These searches may be conducted from time to time without prior announcement.

Authorization & Consent

Initials* I AUTHORIZE any physician, medical practitioner or authorized personnel at any hospital, clinic, other medical or medically related facility approved by Zack Burkett co. to conduct urinalysis and/or blood tests prior to or during my employment by Zack Burkett Co. for the purpose of determining if I have the presence of marijuana, illegal drugs, controlled substances, mind-altering substances, unauthorized prescription drugs, or alcohol in my bodily system.

Initials* I CONSENT to a pre-employment physical (including urinalysis anchor blood tests) to be conducted by any physician, medical practitioner or authorized personnel at any hospital, clinic or other medical or medically related facility approved by Zack Burkett Co.

Initials* I AUTHORIZE any physician, medical practitioner or authorized personnel at any hospital, clinic, or other medical or medically- related facility which conducts such examinations to release all information relating to urinalysis and/or blood tests, all medical records relating to on-the-job injuries, and any and all personal medical information obtained as a result of such examination to Zack Burkett Co.

Initials* I UNDERSTAND that information obtained under these authorizations will be used by Zack Burkett Co. as one factor in determining my eligibility to be employed by or continue to be employed by Zack Burkett Co.

Initials* I AGREE, if injured while on the job, to immediately report such injury to my supervisor and to accept medical treatment from a company approved physician, medical practitioner or authorized personnel at any company approved hospital, clinic, or other medical or medically-related facility.

Initials* I AUTHORIZE Zack Burkett Co. to investigate and verify the facts stated by me in this application and to investigate my worker's compensation and/or industrial accident record in whole or in part by use of a report to be requested from the industrial Foundation of America, 815 North Jefferson, Odessa, Texas, or from any other sources.

Initials* I AUTHORIZE all information services and sources and all of my past employers to release any and all information, whether personal or otherwise, that may or may not be in their records, to Zack Burkett Co.

Initials* I RELEASE all information services and sources and all of my former employers from any and all liability for any damages which may result, either directly or indirectly, from furnishing Zack Burkett Co. information regarding my previous employment or from furnishing Zack Burkett Co. any other information, whether personal or otherwise, that may or may not be on their records.

Initials* I AGREE that any material misrepresentation or omission made by me in this application constitutes my RELEASE of Zack Burkett Co. from liability for damages which may result from Zack Burkett Co. having relied on such misrepresentation or omission as being true and correct and will also constitute grounds for my dismissal.

Initials* I CONSENT, whether as an employment applicant or as an employee to comply, sign and date any and all Policy Authorization and Consent Agreements that arc required of me by Zack Burkett Co., and I UNDERSTAND that failure to do so will cause me to be ineligible for employment or will constitute grounds for my dismissal.

Initials* I, the undersigned, have read, or have had read to me. the above and foregoing Zack Burkett Co. CONTRABAND POLICY FOR EMPLOYEES AND EMPLOYMENT APPLICANTS and AUTHORIZATION AND CONSENT and I UNDERSTAND and AGREE TO SAME.

Signature*

Date*

Date

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