PERSONAL DATA
Name: (first, middle, last)
Address:
City:
State:
Zipcode:
Telephone - Residence:
Telephone - Business:
Telephone - Message:
If driving a truck or vehicle is an essential function of the job for which you are applying,
Driver's License Number:
Social Security Number:
Are you at least 18 years of age?
Are you legally eligible to work in the USA?
Please list any relevant military experience you have:
JOB INTEREST
For what job at this Company are you applying? (Please be specific)
Who referred you to our Company, or what prompted your application here?
Are you willing to work shift work?
Which shift is your preference?
Is there a shift you are not willing to work?
If Yes, which shift?
Are you willing to work rotating shifts?
Are you willing to work weekends?
Have you worked for our Company before?
If Yes, please give dates of employment,
Have you ever applied for work with our Company before?
If Yes, please give dates of employment,
EDUCATION AND TRAINING - Please complete for each school attended.
Please list any currently valid and special motor vehicle, operator licenses or trade/craft certification you hold.
Other special qualifications related to this job or this Company:
WORK HISTORY - Please list your jobs in the exact order of occurrence, begin with current job or most recent job if unemployed.
Most Current or Recent Job:
Name of Employer:
Type of Industry:
Employer's Location:
Employer's Phone:
Dates of Employment: (from Mo/Yr)
Dates of Employment: (to Mo/Yr)
Your Job Title/Responsibility:
Your Supervisor's Name and Title:
Your last rate of pay:
Your Reason for Leaving: (please be specific)
Next Job:
Name of Employer:
Type of Industry:
Employer's Location:
Employer's Phone:
Dates of Employment: (from Mo/Yr)
Dates of Employment: (to Mo/Yr)
Your Job Title/Responsibility:
Your Supervisor's Name and Title:
Your last rate of pay:
Your Reason for Leaving: (please be specific)
Next Job:
Name of Employer:
Type of Industry:
Employer's Location:
Employer's Phone:
Dates of Employment: (from Mo/Yr)
Dates of Employment: (to Mo/Yr)
Your Job Title/Responsibility:
Your Supervisor's Name and Title:
Your last rate of pay:
Your Reason for Leaving: (please be specific)
Next Job:
Name of Employer:
Type of Industry:
Employer's Location:
Employer's Phone:
Dates of Employment: (from Mo/Yr)
Dates of Employment: (to Mo/Yr)
Your Job Title/Responsibility:
Your Supervisor's Name and Title:
Your last rate of pay:
Your Reason for Leaving: (please be specific)
Please explain any gaps in the above dates of employment (from one employer to another) greater than three months.
JOB-RELATED BACKGROUND
Regarding the job for which you have applied, are you familiar with this job and do you understand the basic physical requirements needed to perform it?
If you answered yes to the question above, please answer this question: Are you physically able to perform this job safely and without a significant risk of substantial harm to yourself or to others?
Special Note/Section to Applicants with Disabilities:
You may answer "yes" to this question above if you can perform all essential functions of the job with or without reasonable accommodations. The Company will provide reasonable accommodations to a person with a disability.
However, you still are not required to identify yourself as a disabled person on this Application Form. If you can perform the essential tasks of the job only with an accommodation, then please respond to this question:
How would you perform the tasks, and with what accommodation(s)?
Have you ever been counseled, warned or disciplined for an unsafe work practice or other safety violation in the past year? (Note: A Yes answer may not necessarily bar you from employment here.)
If Yes, please explain:
Have you ever had a "near miss" on the job where you nearly missed being injured or injuring someone else in the past year? (Note: A Yes answer may not necessarily bar you from employment here.) If Yes, please explain:
How many days were you absent from work last year?
Do you ever take any illegal drug (such as, but not limited to) methamphetamine, marijuana, cocaine without a medical prescription? Also, have you taken any illegal drug during the past year without a medical prescription? (Note: A Yes answer may not necessarily bar you from employment here.) If Yes, please explain:
Have you ever been convicted of a felony or have you agreed to a court settlement for a lesser crime after having been charged with a felony? (Note: A Yes answer may not necessarily bar you from employment here.) If Yes, please explain:
AGREEMENT & RELEASE
Please read the following section then use the checkbox to indicate that you have read and understood the Agreement & Release.
I certify that the information I have provided on this Application Form and on my resume (if any) is true to the best of my knowledge.
Regarding this application, I understand that if the Company determines that I have made any false statements, answers or any misrepresentation or any omission of significant information, the Company is entitled to reject my Application, or if hired, to terminate my employment.
In the event I undergo a medical examination or evaluation as part of the job placement process of the Company I agree to supply only information which is true to the best of my knowledge. Regarding this examination or evaluation, I understand that the Company determines that I have made any false oral or written statements or answers or any misrepresentation or any omission of significant information to the Company or to the physician or to his or her representative, the Company is entitled to terminate my conditional or actual employment at any time.
I authorize any person, school, current employer, past employer, physician or organization with knowledge of me or my work to provide the Company or its agent or representative with any information or opinion about me in response to an inquiry by the Company.
I release any such person, employer, physician or organization from any legal liability in making such statements or furnishing any and all information to the Company or to its representative or agent.
I authorize the Company or its agent or representative to check references regarding my employment and investigate any of the statements or answers provided by me on this Application or made to a physician or his or her representative (in the event of a medical examination or evaluation). The only exception to this authorization is where I have specifically requested in writing on this Application Form on the date below that no such inquiry be made.
I understand that my employment at this Company is on an "at will" (that is, mutual consent) basis. Therefore, I agree that either I or the Company has the proper right to terminate my employment with or without cause at any time.
