A & R Diamond Paving & Construction LLC | (503) 851-4492
765 SE Monmouth Cutoff Rd. Dallas OR 97338
EMPLOYMENT APPLICATION
** Please complete the entire Application.
It is the policy of A & R Diamond Paving & Construction LLC to provide equal
employment opportunities to all applicants and employees without regard to any
legally protected status such as race, color, religion, gender, national origin, age,
disability, or veteran status.
Applicant Information
Full Name:
First Name
Last Name
Home Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number of years at this address:
Daytime Phone:
Format: (000) 000-0000.
Social Security Number:
Driver's License (State/Number):
Emergency Contact Who should be contacted if you are involved in an emergency?
Contact Name:
Relationship to you:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Daytime Phone:
Format: (000) 000-0000.
Job Position Applied For:
Full or Part Time?
Salary Desired: $
per
Are you at least 18 years old?
Yes
No
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A & R Diamond Paving & Construction LLC | (503) 851-4492
765 SE Monmouth Cutoff Rd. Dallas OR 97338
How will you get to work?
Are you willing to work any shift, including nights and weekends?
Yes
No
If no, please state any limitations:
If applicable, are you available to work overtime?
Yes
No
If you are offered employment, when would you be available to begin work?
If hired, are you able to submit proof that you are legally eligible for employment in the United States?
Yes
No
SKILLS
Check those skills that you have. List any other skills that may be useful for the job you are seeking. Enter the number of years of experience, and circle the number that corresponds to your ability for each particular skill. (One represents poor ability, while five represents exceptional ability.)
Ability or Skill Years of Experience Rating
Asphalt
Concrete
Seal Coating
Truck Driving
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A & R Diamond Paving & Construction LLC | (503) 851-4492
765 SE Monmouth Cutoff Rd. Dallas OR 97338
Employment History
List your current or most recent employment first.
Please list all jobs (including self-employment and military service) that you have
held, beginning with the most recent, and list and explain any gaps in employment.
**If additional space is needed, continue on the back page of this application.
Employer Name:
Supervisor Name:
Address:
City/State/ZIP:
Job Duties:
Reason for Leaving:
Dates of Employment (Month/Year):
Employer Name:
Supervisor Name:
Address:
City/State/ZIP:
Job Duties:
Reason for Leaving:
Dates of Employment (Month/Year):
Employer Name:
Supervisor Name:
Address:
City/State/ZIP:
Job Duties:
Reason for Leaving:
Dates of Employment (Month/Year):
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A & R Diamond Paving & Construction LLC | (503) 851-4492
765 SE Monmouth Cutoff Rd. Dallas OR 97338
Education and Training
College/University Name and Address
Did you receive a degree?
Yes
No
If yes, degree(s) received:
High School/GED Name and Address
Did you receive a degree?
Yes
No
Other Training (graduate, technical, vocational):
Please indicate any current professional licenses or certifications that you hold:
Awards, Honors, Special Achievements:
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A & R Diamond Paving & Construction LLC | (503) 851-4492
765 SE Monmouth Cutoff Rd. Dallas OR 97338
References
List any two non-relatives who would be willing to provide a reference for you.
Name:
First Name
Last Name
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Telephone:
Format: (000) 000-0000.
Relationship:
Name:
First Name
Last Name
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Telephone:
Format: (000) 000-0000.
Relationship:
ADDITIONAL INFORMATION
Please provide any other information that you believe should be considered, including whether you are bound by any agreement with any current employer:
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A & R Diamond Paving & Construction LLC | (503) 851-4492
765 SE Monmouth Cutoff Rd. Dallas OR 97338
Certification
I certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for the rejection of my application or, if employment commences, immediate termination. I authorize A & R Diamond Paving & Construction LLC to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades. I authorize those persons designated as references to fully and freely communicate information regarding my previous employment and education.
I HAVE CAREFULLY READ THE ABOVE CERTIFICATION, AND I UNDERSTAND AND AGREE TO ITS TERMS.
Applicant Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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