Taft Electric Job Application Form

32 Road 5219, Bloomfield, NM 87413 Office: (505) 333-7398 - Fax: (505) 632-8905 Email: info@tei-nm.com

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job

related disability, or any other protected group status.
Date*

MonthDayYear
Date
First*
Middle
Last*
Date of Birth*

MonthDayYear
Date
Social Security No*
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Drivers License #
State
Exp Date

MonthDayYear
Date
Do you have a legal right to be employed in the United States? Are you over the age of 18?*

YesNo
Race

WhiteAfrican AmericanAmerican IndianAsianNative Hawaiian
Ethnicity

HispanicNon-Hispanic

General
Are you currently Employed*

YesNo
If yes where
Have you applied at this company before?*

YesNo
If so when
Position applying for
Salary Desired

EDUCATION
High School
High School Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Years Attended
Did you Graduate?
Subjects Studied
College
College Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Years Attended
Did you Graduate?
Subjects Studied
Trade
Trade Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Years Attended
Did you Graduate?
Subjects Studied
List any Special Skills or Qualifications:

Employment History

(LIST BELOW LAST FOUR EMPLOYERS, STARTING WITH THE MOST RECENT ONE FIRST) DATE MONTH AND YEAR, NAME/ADDRESS/PH# OF EMPLOYER, SALARY & POSITION
From:

MonthDayYear
Date
To:

MonthDayYear
Date
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Salary
Position
Reason for Leaving
From

MonthDayYear
Date
To

MonthDayYear
Date
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Salary
Position
Reason For Leaving
From

MonthDayYear
Date
To

MonthDayYear
Date
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Salary
Position
Reason For Leaving
From

MonthDayYear
Date
To

MonthDayYear
Date
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Salary
Position
Reason for Leaving
May we contact your current/previous employers?

YesNo
If Not Why

References

Give below the names of 3 persons not related to you, whom you have known at least 1 year
Reference 1 Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business
Years Known
Reference 2 Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business
Years Known
Reference 3 Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business
Years Known

AUTHORIZATION
"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. Iauthorize investigation of all statements contained herein and the references and the employers 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 the company from all liability for any damage that may result from utilization of such information Ialso authorize Taft Electric, Inc's. insurance agent, Kysar Insurance to process my driver's license information through the Motor Vehicle Department to check for any/all driving violations and to determine whether I am insurable through Kysar Insurance. If it is determined that I am not insurable through Kysar Insurance, I will not be offered a position with Taft Electric, Inc. I also understand that if offered a job, it may be conditioned on the results of a physical examination and drug test. If hired, I agree to abide by all the rules and policies of the employer. I also understand and agreee that no representative of Taft Electric Inc. has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws."
DATE*

MonthDayYear
Date
SIGNATURE*

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General

EDUCATION

High School

College

Trade

Employment History

References

AUTHORIZATION