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Employment Application Form
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Indicates required field
Name
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First
Last
Email
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Phone Number
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Social Security No.
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Date of Birth
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Address
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Line 1
Line 2
City
State
Zip Code
Country
How long at current address?
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Are you currently authorized to work in the United States?
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Yes
No
If yes, can you provide proof of eligibility to work?
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Yes
No
* Proof of eligibility will be required if hired.
Position applied for:
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Wage desired:
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Are you willing to travel as part of your employment?
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Yes
No
Days available to work:
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No Preference
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
How many hours can you work weekly?
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Based on your understanding of the duties of the job you are applying for, are you able to perform these duties with or without accommodations?
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Without Accommodations
With Accommodations
If accommodations are needed, please explain:
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Have you worked for this company before?
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Yes
No
Where?
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Dates of previous employment with this company:
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Position and Rate of Pay
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When are you available to start work?
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Are you now employed?
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Yes
No
If not, how long since leaving last employment?
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Who referred you?
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Employment desired:
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Full Time Only
Part Time Only
Full Time or Part Time
Education
High School
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Address
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Years Completed
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Major & Degree
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College
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Address
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Years Completed
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Major & Degree
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Business or Trade School
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Address
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Years Completed
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Major & Degree
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Professional School
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Address
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Years Completed
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Major & Degree
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Have you ever been convicted of a crime which is substantially related to the functions or qualifications of the job for which you are applying?
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Yes
No
A conviction record will not necessarily disqualify you from employment.
If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation:
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Do you have a valid Driver License?
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Yes
No
If yes, please provide Driver's license number, state of issue, license class:
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What is your means of transportation to work?
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Have you had any accidents or moving violations during the past three years?
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Yes
No
If yes, how many?
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List two references other than relatives:
Name
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Name
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Position
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Position
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Company
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Company
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Address
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Address
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Telephone
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Telephone
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Complete the following if you are applying for office position only:
Typing
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Yes
No
WPM (Words per Minute)
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10-Key
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Yes
No
Computer Skills
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PC
Mac
Please provide computer and software knowledge below:
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Work Experience
Please list your work experience for the past seven years beginning with your most recent job held. If you are self-employed, give firm name. Attach additional sheets if necessary.
Name of Employer
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Phone Number
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Name of Last Supervisor
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Employment Dates
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Starting and ending pay or salary
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List the jobs held, duties performed, skills used or learned, advancements or promotions while you worked at this company
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Your last job title
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Reason for leaving (be specific)
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Name of Employer
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Phone Number
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Name of Last Supervisor
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Employment Dates
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Starting and ending pay or salary
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List the jobs held, duties performed, skills used or learned, advancements or promotions while you worked at this company
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Your last job title
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Reason for leaving (be specific)
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Name of Employer
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Phone Number
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Name of Last Supervisor
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Employment Dates
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Starting and ending pay or salary
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List the jobs held, duties performed, skills used or learned, advancements or promotions while you worked at this company
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Your last job title
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Reason for leaving (be specific)
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Current Training Certificates
Name
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First
Last
Date
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Job Title
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Please provide copies of your Current Training Certificates
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Max file size: 20MB
Check off Current Training Certificates
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40 Hours HazWoper
8 Hour HazWoper Refresher
First Aid/CPR
Heavy Equipment
Confined Space
Defensive Driving
TWIC
Asbestos Abatement
Lead
List Others Current Training Certificates
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Use this space to elaborate on any background, experience or qualifications that you believe should be considered in evaluating your qualifications for employment. You may include hobbies, volunteer experience and other activities you believe relevant. Please omit any information that would disclose your race, gender, age, marital status, ethnic origin, religious or political affiliations or disability:
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Have you ever been in the armed forces?
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Yes
No
Are you now a member of the National Guard?
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Yes
No
Specialty
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Dates Entered and Discharged
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May we contact your present employer?
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Yes
No
PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY:
I certify that the facts contained in this application are true and complete to the best of my knowledge. I understand that any false statement on this application or omission of fact on either this application or during the pre-employment process will result in my application being rejected, or, if I am hired, in my employment being terminated.
I also understand that any offer of employment is conditioned on the completion of pre-employment test and documentation. I will, upon request, sign all necessary consent forms.
I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended) hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application.
I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand I have the right to: review information provided by previous employers, have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer, and have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.
In compliance with Federal & 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
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Authorize by Printing Name
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