| *Required |
| BASIC INFORMATION: |
| E-mail Address: * |
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| Date of Application: |
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Position(s) applied for:
(Use Ctrl key to multi select) |
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| First Name: * |
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| Middle Initial: |
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| Last Name: * |
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| Address: * |
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| City:* |
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| State: * |
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| Zip code: * |
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| Have you lived at this address for three years or
more? |
Yes
No |
| Previous Address: |
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| Did you live at this address for three years or more? |
Yes
No |
| Telephone Number(s): * |
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| List other name(s) under which you attended school
or were employed: |
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| How did
you learn about us? |
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Employment Agency
Friend
Relative
Walk-in
Other |
| If you are under 18 years of age, can you provide
required proof of your eligibility to work? |
Yes
No |
| Note: Proof of citizenship
or immigration status will be required upon employment. (An I-9 form
must be completed.) |
| Have you ever filed an application with us before?
* |
Yes
No |
| If yes, give date: |
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| Are you currently employed? |
Yes
No |
| May we contact your present employer? |
Yes
No |
| Are you currently on layoff status and subject to
recall? |
Yes
No |
| Have you ever been convicted of, or pled guilty or
no contest to a misdemeanor or a felony such as fraud, embezzlement
or misappropriation of funds, or also use of financial instruments,
or of any other crime involving honesty? (An affirmative answer will
not necessarily preclude employment.) |
Yes
No |
| If yes, give date, place, charge and disposition: |
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| Do you have any limitations regarding hours that
you can work? |
Yes
No |
| If yes, explain: |
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| Do you have any travel restrictions? |
Yes
No |
| If yes, list and explain them: |
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| Do you have transportation? |
Yes
No |
| Do you have any friends or relatives employed by
this company? |
Yes
No |
| If yes, list name(s): |
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| When are you available for work? |
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| DO YOU HAVE A CURRENT: |
| First Aid Certification: |
Yes
No |
| Expiration Date: |
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| Certifying Agency: |
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| CPR Certification: |
Yes
No |
| Expiration Date: |
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| Certifying Agency: |
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| OSHA 10 Hour Construction Safety Certification: |
Yes
No |
| U.S. MILITARY SERVICE: |
| Branch of Service: |
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| Length of Service: |
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| Rank/Rate at discharge: |
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| Are you a member of the Armed Services Reserve? |
Yes
No |
Note to Applicants:
DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE
REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING. |
| Are you fully able,
with or without reasonable accommodation, to perform the essential
functions of the job for which you applied? |
Yes
No |
| Describe
how you would perform the job with or without a reasonable accommodation: |
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| Do you have a current Drivers License? * |
Yes
No |
| State: |
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| License Number: |
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| Class: |
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| Expiration Date: |
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| List all moving motor violations (other than parking)
for the last 3 years: |
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| EDUCATION: |
| Name & Address of High School or GED: |
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| Course of Study: |
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| Years Completed: |
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| Diploma/Degree: |
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| Name & Address of College: |
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| Course of Study: |
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| Years Completed: |
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| Diploma/Degree: |
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| Name & Address of Trade School: |
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| Course of Study: |
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| Years Completed: |
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| Diploma/Degree: |
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| Name & Address of Apprenticeship: |
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| Course of Study: |
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| Years Completed: |
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| Diploma/Degree: |
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| Name & Address - Military: |
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| Course of Study: |
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| Years Completed: |
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| Diploma/Degree: |
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| Name & Address of Correspondence: |
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| Course of Study: |
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| Years Completed: |
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| Diploma/Degree: |
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| Name & Address - Other (Specify): |
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| Course of Study: |
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| Years Completed: |
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| Diploma/Degree: |
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EMPLOYMENT EXPERIENCE:
Start with your present or last job. Include all employment
and be complete, including any job-related military service assignments
and volunteer activities. You my exclude organizations which indicate
age, race, color, religion, gender, national origin, disability or
other protected status.
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| Name of Employer
#1: |
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| Address (city & state): |
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| Phone: |
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| May we call you at this number? |
Yes
No |
| Date started: |
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| Starting salary/wage: |
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| Starting position: |
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| Date stopped: |
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| Ending salary/wage: |
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| Position at time of leaving: |
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| May we contact your present employer prior to any
employment offer? |
Yes
No |
| Name & Title of supervisor: |
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| Reason for leaving: |
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| Brief description of your responsibilities: |
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| Name of Employer
#2: |
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| Address (city & state): |
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| Phone: |
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| May we call you at this number? |
Yes
No |
| Date started: |
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| Starting salary/wage: |
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| Starting position: |
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| Date stopped: |
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| Ending salary/wage: |
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| Position at time of leaving: |
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| May we contact your present employer prior to any
employment offer? |
Yes
No |
| Name & Title of supervisor: |
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| Reason for leaving: |
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| Brief description of your responsibilities: |
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OTHER EMPLOYMENT INFORMATION:
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| Comments (including explanation of any gaps in employment): |
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| List professional, trade, business civic activities
and offices held. (You may exclude membership which would reveal gender,
race, religion, national origin, age, ancestry, disability or other
protected status): |
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| REFERENCES: (Do not list relatives or employers) |
| Reference Name #1: * |
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| Address: |
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| Phone: |
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| Reference Name #2: * |
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| Address: |
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| Phone: |
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| Reference Name #3: * |
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| Address: |
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| Phone: |
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IMPORTANT AUTHORIZATION AND UNDERSTANDING
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1. Completeness and accuracy of information. I represent
that all of the information now or hereafter given by me in support
of my application for employment is true and complete. I understand,
that if I am hired, any false or misleading information in support
of my application may subject me to discharge at any time during
the period of my employment.
2. Authorization for release of information and release from liability.
I authorize you to verify any of the information given during the
application process with appropriate individuals, companies, institutions,
or agencies and I authorize them to release such information as you
require, including my prior disciplinary employment record, without
any obligation to give me written notice of disclosure. I hereby
release you and them from any liability whatsoever as a result of
such inquiries and disclosures. A photocopy or other electronic reproduction
of the authorization/release is binding, and may be relied upon.
3. Employment at will. I understand that if I am employed, I will
be an employee at will. This means that either the employer or the
employee may terminate the employment relationship with or without
cause at any time.
4. No written, oral, or implied contracts. I understand that any
written Company documents, oral statements, or formal or informal
policies are not to be construed as granting an express or implied
employment contract and that I am not entitled to rely upon any such
documents, statements or Company policies as stating employment terms.
The employment relationship with the Company may be modified only
in writing directed to be by the President of the Company.
5. Benefits may be altered. I understand that the Company at its
option may change, delete, suspend, or discontinue any part or parts
of its benefit program at any time without prior notice, both while
persons are actively employed and while retired or otherwise separated
from employment with the Company.
6. I understand that a test for drug and alcohol misuse may be required
as part of the interview process, and I hereby authorize the release
of test results to the Company. I hereby consent to the performance
of such medical examination and testing. I waive all claims arising
out of these procedures against the Company and those performing
the examination and tests. I understand and consent that as a condition
of continued employment, I will submit to drug and alcohol testing
in the future. I authorize the release of any such subsequent testing
to the Company and waive all claims against it or those performing
the examination and tests. I understand that I will be subject to
immediate termination for failing to submit to examination or testing.
7. If an employment relationship is established, I agree to wear
or use all protective clothing or devices as may be required by the
Company and to comply with all safety policies and procedures.
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| I acknowledge that I have read and understand the
above statement in its entirety, and have had the opportunity to ask
questions regarding any aspect of this application, and that I accept
the above terms. * |
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Yes
No
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