Employment Application Form:
Kelly Cortum Inc. is an Equal Employment Opportunity and Affirmative Action Employer committed to excellence through diversity. Employment offers are made on the basis of qualifications, and without regard to race, sex, religion, national or ethnic origin, disability, age, veteran status, or sexual orientation.
Personal Information:
Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
-
Area Code
Phone Number
E-mail
*
Are you 18 Years of age or older?
*
Yes
No
Are You a U.S. Citizen?
Yes
No
Employment Desired:
Position Applying For
*
Please Select
Equipment Operator
Laborer / Pipe Layer
Dump Truck Driver
Low Boy Driver
Date You Can Start
*
-
Month
-
Day
Year
Date Picker Icon
Salary Desired
*
Have You Worked Here Before?
*
Yes
No
Have You Applied Here Before?
*
Yes
No
Do you currently have a CDL?
*
YES
NO
Education:
High School
*
Name of High School Attended
Number of Years Attended
*
Graduated?
*
Yes
No
College
Name of College/University Attended
Number of Years Attended
Graduated?
Yes
Area of Study/Degree
Trade School/Other
Name of Trade/Technical/Other School Attended
Number of Years Attended
Graduated?
Yes
Area of Study/Degree
Skills/Qualifications:
Skills
*
List any relevant skills
Qualifications
*
List any relevant certifications or qualifications
Current Employment:
Current Employer
*
Name of Current Employer or NONE if not Employed
Position
*
Salary
*
Reason for Leaving?
*
Start Date
*
-
Month
-
Day
Year
Date Picker Icon
May We Contact?
Yes
No
Previous Employment:
Previous Employer
*
Name of Previous Employer
Position
*
Salary
*
Reason for Leaving?
*
Start Date
*
-
Month
-
Day
Year
Date Picker Icon
End Date
*
-
Month
-
Day
Year
Date Picker Icon
Previous Employer
Name of Previous Employer
Position
Salary
Reason for Leaving?
Start Date
-
Month
-
Day
Year
Date Picker Icon
End Date
-
Month
-
Day
Year
Date Picker Icon
References:
Reference 1
*
Name of Reference
Relationship
*
Years Acquainted
*
Phone
*
Email
Reference 2
Name of Reference
Relationship
Years Acquainted
Phone
Email
Reference 3
Name of Reference
Relationship
Years Acquainted
Phone
Email
Cover Letter & Resume (Optional):
Cover Letter
Resume
Send Application:
Please Read Carefully And By Submitting That You Understand And Accept This Information.By clicking the submit button below, I certify that the information on this application and its supporting documents are accurate and complete. I understand and agree that failure to fully complete the form, or misrepresentation or omission of facts, represents grounds for elimination from consideration of employment, or termination after employment if discovered at a later date. I authorize Kelly Cortum Inc. to investigate, without liability, to make full response to any inquiries in connection with this application for employment. If requested, I agree to submit to a physical exam, criminal and credit background investigation, and/or screening for illegal substances upon conditional offer of employment. I understand that this document is NOT an offer of employment, and that an offer of employment, if tendered, does NOT constitute a contract for continued guaranteed employment. I understand that staff employees of Kelly Cortum Inc. serve at-will, and the employment relationship may be terminated at anytime by either party, for any or no reason, other than a reason prohibited by law. IF employed, I will be required to furnish proof of eligibility to work in the United States, and to comply with company and departmental regulations. I understand that any benefits I receive may be subject to change or discontinuation at any time without prior notice. I understand that the first SIX MONTHS of regular employment represent a provisional period, during which I would not be eligible to apply for transfer or promotion and during which I may be terminated without right of appeal.
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