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Paul's Plumbing and Heating, Inc. is an equal opportunity employer and adheres to the principles and practices outlined in the Civil Rights Act of 1964, which prohibits discrimination in employment on the basis of race, sex, religion or national origin and Public Law 90-202 which prohibits discrimination based on age. This application will be given every consideration, but its receipt does not imply that the applicant will be employed. Each question should be answered in a complete and accurate manner as no action can be taken on this application until all questions have been answered. This questionnaire is a pre-employment application only. __________________________________ Personal: __________________________________ Date:___________ Name:____________________________________________ Phone( )__________________ Present Address:____________________City:_________________State:___Zip____________ Social Security No.:___________________________ Are you over 18: Yes____No___ Are you a citizen of the U.S. or do you have the legal right to be employed in the U.S.? Yes_____No____ Have you ever been convicted of any crime (excluding minor traffic violations) including DWI? Yes___No___ If yes state the offense, location, date and deposition:_______________________________________________________________ __________________________________________________________________________________________________ Who should be contacted in case of an emergency? Name:______________________________________ Relationship:___________________________________________ Street Address___________________________City_______________________State_____Zip____________________ Drivers License: State________Number________________________________Type_____________________________ _________________________________ Employment Desired ________________________________ Are you seeking_____Fulltime _____Part Time _____ Temporary of Summer Employment Position applied for_______________________________Salary Desired:______________________________________ Have you ever applied with us before? Yes___No___ Date Available to start____________________________________ Have you ever worked here before? Yes___No___ If you ever applied or worked for us, state when and where you applied and/or worked:_______________________________________________________________________________ How did you learn of our company and/or position?_________________________________________________________________________ Are you now or do you expect to be involved in any other business or employment? Yes___No___ Are there any days or hours you would be unable or unwilling to work? Yes___No___ If yes please list_________________________________________________________________________________________________________________________ _____________________________ Military _____________________________ Have you ever served in the military? Yes___No___ Service Branch________________________________________ Date Entered_____________ Date Separated_______________ Final Rank____________________________________ Were you separated from the service with any degree of disability? If so, what degree____________________________ Are you a member of a reserve organization? Yes___No___ _________________________ Health ________________________ Do you have any physical defect, illness or medical injury that may limit your ability to perform the particular job for which you are applying? Yes___No___ If yes, please describe_____________________ _________________________________________________________________________________________________ Date of last exam_____________________________Results_______________________________________________ Have you ever been injured on the job? Yes___No___ If yes, please describe:________________________________ _________________________________________________________________________________________________ Nature of injury Employer when injured Year Cause of Injury 1. 2. 3. Are you currently taking any medication for any illness or condition? Yes___No___ If yes, what type of medication?________________________________________________________________________________________ Have you ever used any illegal drug, including marijuana, in the past twelve months? Yes___No___ Have you ever received treatment for alcohol or drug use? Yes___No___ Are you willing to take a physical exam and a urinary drug screen at our expense? Yes___No___ Days lost in the last two years due to illnes________Reason_________________________________________ _____________________________ Education _____________________________ Name, Address & Location Dates: Graduate Courses Studied High School? From:____To:____ Yes___No___ Diploma: College: From:____To:____ Yes___No___ Diploma:
Trade School From:___To:___ Yes___No___ Diploma:
Are you planning to pursue further studies? Yes___No___ If so, when and what courses:___________________ _____________________________________________________________________________________________ List any scholastic honors, offices held and activities involved in during high school or college:________________ _____________________________________________________________________________________________ List and describe any other school or specialized training:______________________________________________ ______________________________________________________________________________________________ ___________________________ Work History __________________________ List names of employers in consecutive order with present or last employer listed first. Account for all periods of time including military service and any periods of unemployment. If self-employed, give the firm name and supply business references. Name of Employer:_________________________Address_______________________State____Zip_____________ Name and title of last supervisor____________________________________________________________________ Date employed From:_____________To:____________Pay Starting:$_________Pay Ending:$_________ Telephone ( ) Name of business:_____________________________________________________ Reason for leaving:_______________________________________________________________________________ Title:_________________Duties:____________________________________________________________________ _______________________________________________________________________________________________ ____________________________________________________________________ Name of Employer:_________________________Address_______________________State____Zip__________ Name and title of last supervisor_________________________________________________________________ Date employed From:_____________To:____________Pay Starting:$_________Pay ending:$_______________ Telephone ( ) Name of business:__________________________________________________ Reason for leaving:____________________________________________________________________________ Title:_________________Duties:_________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________ Name of Employer:_________________________Address_______________________State____Zip___________ Name and title of last supervisor__________________________________________________________________ Date employed From:_____________To:____________Pay Starting:$_________Pay ending:$_______________ Telephone ( ) Name of business:___________________________________________________ Reason for leaving:_____________________________________________________________________________ Title:_________________Duties:__________________________________________________________________ _____________________________________________________________________________________________ ____________________________________________________________________ Name of Employer:_________________________Address_______________________State____Zip___________ Name and title of last supervisor__________________________________________________________________ Date employed From:_____________To:____________Pay Starting:$_________Pay ending:$_______________ Telephone ( ) Name of business:___________________________________________________ Reason for leaving:_____________________________________________________________________________ Title:_________________Duties:__________________________________________________________________ _____________________________________________________________________________________________ ____________________________________________________________________ If you worked in any of your previous positions under another name, give that name:________________________ Are you presently employed? Yes___No___ If yes, may we contact your present employer? Yes___No___ ____________________________ Special Skills ____________________________ Do you type? Yes___No___ Words per minute:_____________ Do you take Shorthand? Yes___No___ Words per minute:_____________ Have you had any computer or word processing experiences or training?Yes___No___ If yes, please describe the extent:________________________________________________________________________________________ What languages do you speak fluently?_____________________________________________________________ Use the space below to describe why you are interested in working for us and to list those skills and abilities which you feel particularly qualify you for a position with us. Please attach a resume if you have one available.______________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ___________________________ References ___________________________ Give three references, not relatives or former employers Name Address Phone Occupation
__________________________ Affidavit __________________________ I certify that the answers given by me to the foregoing questions and statements are true and correct without consequential omissions of any kind whatsoever. I understand that any misleading or incorrect statements may render this application void and if employee, would be cause for my termination. I further agree that you shall not be liable in any respect if my employment is terminated because of falsity of statements, answers or omissions made by me in the questionnaire. I also authorize the companies, schools or persons named above to give any information regarding my employment character and qualifications and hereby said companies, were made without reservations and agree to expressly waive all provision of law prohibiting any physician, person, hospital or other institution from disclosing to us any information regarding treatment rendered now and in the future. I further understand that the taking of drug tests are a condition of employment and refusal to take such tests when asked will subject me to termination. I also understand that no person is authorized to enter into any written or verbal employment contract on behalf of us without the express written consent of the President. I understand my employment is at will. I further understand that I will be given an "employee handbook" outline our rules and regulations Signature__________________________________ Date_____________________________ __________________________ Company Use Only __________________________ Interviewed By:_____________________ Date:______________ Driver's License#__________________________ Interviewers Remarks:__________________________________________________________________________ |
Copyright © 2000 Paul's Plumbing, Heating and A/C
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