NAME *
NAME
POSITION APPLYING FOR *
APPLICANT'S STATEMENT: I UNDERSTAND THAT CAPITAL CONCRETE, INC. IS COMMITTED TO PROVIDING EQUAL OPPORTUNITY IN ALL EMPLOYMENT PRACTICES, INCLUDING BUT NOT LIMITED TO SELECTION, HIRING, PROMOTION, TRANSFER AND COMPENSATION TO ALL QUALIFIED APPLICANTS AND EMPLOYEES WITHOUT REGARD TO AGE, RACE, COLOR, RELIGION, NATIONAL ORIGIN, DISABILITY, MARITAL STATUS, VETERAN STATUS OR ANY OTHER LEGALLY PROTECTED STATUS. I CERTIFY THAT ANSWERS GIVEN HEREBY ARE TRUE AND COMPLETE. I AUTHORIZE INVESTIGATION OF ALL STATEMENTS IN THIS APPLICATION FOR EMPLOYMENT AS MAY BE NECESSARY IN ARRIVING AT AN EMPLOYMENT DECISION. THIS APPLICATION FOR EMPLOYMENT SHALL BE CONSIDERED FOR A PERIOD OF TIME NOT TO EXCEED 45 DAYS. ANY APPLICANT WISHING TO BE CONSIDERED FOR EMPLOYMENT BEYOND THIS TIME PERIOD SHOULD INQUIRE AS TO WHETHER OR NOT APPLICATIONS ARE BEING ACCEPTED AT THAT TIME. I HEREBY UNDERSTAND AND ACKNOWLEDGE THAT UNLESS OTHERWISE DEFINED BY APPLICABLE LAWS, ANY EMPLOYMENT RELATIONSHIP WITH THIS COMPANY IS OF AN "AT WILL" NATURE, WHICH MEANS THAT THE EMPLOYEE MAY RESIGN AT ANY TIME AND EMPLOYER MAY DISCHARGE THE EMPLOYEE AT ANY TIME WITH OR WITHOUT CAUSE. IT IS FURTHER UNDERSTOOD THAT THIS "AT WILL" EMPLOYMENT RELATIONSHIP MAY NOT BE CHANGED BY ANY WRITTEN DOCUMENTS. *
Applicant Hired__________________________Rejected_____________________________ Date employed__________________ Point Employed_______________________ Department__________________________________Classification____________ (If rejected, summary report of reasons should be placed in file.) Signature of Interviewing Officer________________________________________
PERSONAL INFORMATION
ADDRESS
PHONE NUMBER: CIRCLE WHICH ONE APPLIES
SSN
DATE OF BIRTH (Required For Commercial Drivers)
EMAIL ADDRESS
IF YES, PLEASE GIVE DATE AND DETAILS
IF YES, PLEASE LIST THEIR NAME AND RELATIONSHIP
PLEASE LIST YOUR DESIRED SALARY RANGE:
IF YES, PLEASE GIVE DATES AND DETAILS:
IF YES, WHAT CLASS?
HAVE YOU EVER BEEN CITED FOR A TRAFFIC VIOLATION OF ANY KIND WITHIN THE LAST 5 YEARS. IF YES, PLEASE GIVE DATES AND DETAILS:
LIST ALL DRIVER LICENSES OR PERMITS HELD IN THE PAST 3 YEARS: STATE, LICENSE NUMBER, TYPE, EXPIRATION DATE *
EMERGENCY INFORMATION-IN CASE OF AN ACCIDENT OR EMERGENCY, WHO SHOULD WE CALL? *
RELATIONSHIP
ADDRESS
ADDRESS
PHONE NUMBER
EDUCATION : HIGH SCHOOL
COLLEGE/UNIVERSITY
COURSE OF STUDY/ MAJOR
BUSINESS OR TECHNICAL SCHOOL ATTENDED
OTHER SCHOOLING
BRANCH OF SERVICE
DATES
RANK
JOB TITLE
PLEASE DESCRIBE ANY SPECIALIZED TRAINING, APPRENTICESHIP, SKILLS AND EXTRA-CURRICULAR ACTIVITIES:
PREVIOUS RESIDENCE: LIST ADDRESSES FOR THE LAST THREE (3) YEARS:
RECORD OF PREVIOUS EMPLOYMENT: PRESENT OR LAST EMPLOYER NAME
ADDRESS
PHONE NUMBER
SUPERVISOR
EMPLOYMENT DATES
JOB TITLE
STARTING PAY
FINAL PAY
REASON FOR LEAVING
PREVIOUS EMPLOYER 2
ADDRESS
PHONE NUMBER
SUPERVISOR
EMPLOYMENT DATES
JOB TITLE
STARTING PAY
FINAL PAY
REASON FOR LEAVING
TO (PREVIOUS EMPLOYER):_____________DATE___________THE PERSON NAMED ABOVE HAS APPLIED TO THIS COMPANY FOR EMPLOYMENT. YOUR FIRM IS LISTED BY THE APPLICANT AS A PAST EMPLOYER. PLEASE COMPLETE THE FOLLOWING ITEMS AND RETURN TO OUR COMPANY IMMEDIATELY (BY FAX, IF POSSIBLE AT 757-627-1776). FAILURE TO FURNISH INFORMATION AS REQUIRED BY 49 CFR 382.405 (F) AND 382.413 IS A VIOLATION OF DOT REGULATIONS AND MAY RESULT IN A FINE AND/OR CIVIL LIABILITY. THIS CERTIFIES THAT THE APPLICATION WAS COMPLETED BY ME, AND THAT ALL ENTRIES ON IT AND INFORMATION IN IT ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
DATE
APPLICANT'S SIGNATURE