Maverick Oxygen Employment Application Form

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* This field is required.Notice To Applicants For Employment-Maverick Oxygen & Respiratory Equipment, LLC is an "at will" employer, which means that either the employer or the employee may terminate the employment relationship at any time for any or no reason with or without notice.
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* This field is required.Notice To Applicants For Employment-Applicants May Be Tested For Illegal Drugs
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Name:* This field is required.
First Name
Last Name
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Phone Numbers:* This field is required.Leave blank if not applicable
Please enter your home phone
Please enter your cell phone
Please enter your work phone
5
E-mail Address:* This field is required.
6
Address:* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Other
Country
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Days Available For WorkScroll down to select all options
Yes
No
Monday
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Row 0, Column 1
Tuesday
Row 1, Column 0
Row 1, Column 1
Wednesday
Row 2, Column 0
Row 2, Column 1
Thursday
Row 3, Column 0
Row 3, Column 1
Friday
Row 4, Column 0
Row 4, Column 1
Saturday
Row 5, Column 0
Row 5, Column 1
Sunday
Row 6, Column 0
Row 6, Column 1
Can Work Nights?
Row 7, Column 0
Row 7, Column 1
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Can Work Nights?
Yes
Row 0, Column 0
No
Row 0, Column 1
Yes
Row 1, Column 0
No
Row 1, Column 1
Yes
Row 2, Column 0
No
Row 2, Column 1
Yes
Row 3, Column 0
No
Row 3, Column 1
Yes
Row 4, Column 0
No
Row 4, Column 1
Yes
Row 5, Column 0
No
Row 5, Column 1
Yes
Row 6, Column 0
No
Row 6, Column 1
Yes
Row 7, Column 0
No
Row 7, Column 1
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Employment Desired
Part Time
Full Time
Full or Part Time
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Position applied for and salary desired
Position Applied For
Salary/Wage Desired
10
Education
Name
Location/Mailing Address
Years Completed
Major/Degree
High School
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
College
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Trade School
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Professional School
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
High School
College
Trade School
Professional School
Name
Row 0, Column 0
Location/Mailing Address
Row 0, Column 1
Years Completed
Row 0, Column 2
Major/Degree
Row 0, Column 3
Name
Row 1, Column 0
Location/Mailing Address
Row 1, Column 1
Years Completed
Row 1, Column 2
Major/Degree
Row 1, Column 3
Name
Row 2, Column 0
Location/Mailing Address
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Years Completed
Row 2, Column 2
Major/Degree
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Name
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Location/Mailing Address
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Years Completed
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Major/Degree
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Have You Been Convicted Of A Crime?
YESNO
12
If yes, explain number of conviction(s), nature of offense(s), how recently such offence(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.If not applicable, leave blank
Huge
Large
Normal
Small
Ok
Ok
13
Do you have a driver's license?
YESNO
14
Driver's License Information
Driver's license number
State of issue
Driver's license expiration date
What is your means of transportation to work?
Operator
Commercial
Chauffer
What type of driver's license do you have? You can select more than 1
15
CDL InformationSelect all that apply
Class A
Class B
Class C
Hazardous Material
Tanker
Double/Triples
Airbrakes
16
Accidents and Violations
Have you had any accidents in the past three years?
How many?
Have you had any moving violations during the past three years?
How many?
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Additional Training or Certifications:
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How were you referred to us?
Walk-In
Employee
Newspaper Ad
Other (please specify)
19
If you answered "other" or "employee" please be more specific here
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References

Please list two (2) references that are familiar with your work life.
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Reference 1
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Name:
First Name
Last Name
23
Phone Number
Area Code
Phone Number
24
Years Known:
25
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
United States
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
26
Reference 2
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Name:
First Name
Last Name
28
Phone Number
Area Code
Phone Number
29
Years Known:
30
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
United States
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
31
An application form sometimes makes it difficult for an individual to adequately summarize a complete background, Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying.
32
Military
Please Select
Please Select
Yes
No
Have you ever been in the armed forces
Please Select
Please Select
Yes
No
Are you a member of the National Guard
Specialty
Date Entered
Discharge Date
33
Employer 1
34
Previous Employer
Name
Address
Phone #
Name of last supervisor
Employment Dates- Start
Employment Dates-End
35
Previous Employer Continued
Last job title
Starting Pay
Ending Pay
Reason for leaving
List the jobs held,duties performed, skills used or learned, advancements or promotions while you worked at this company
36
Employer 2
37
Previous Employer
Name
Address
Phone #
Name of last supervisor
Employment Dates- Start
Employment Dates-End
38
Previous Employer Continued
Last job title
Starting Pay
Ending Pay
Reason for leaving
List the jobs held,duties performed, skills used or learned, advancements or promotions while you worked at this company
39
Employer 3
40
Previous Employer
Name
Address
Phone #
Name of last supervisor
Employment Dates- Start
Employment Dates-End
41
Previous Employer Continued
Last job title
Starting Pay
Ending Pay
Reason for leaving
List the jobs held,duties performed, skills used or learned, advancements or promotions while you worked at this company
42
May we contact your present employer?
YESNO
43
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