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EMPLOYMENT APPLICATION

PERSONAL INFORMATION

First Name Last Name

Address Email

City State / Zip Code
   

Home Phone Mobile Phone

Have you ever worked for us? If yes, when?
Yes  No  

Starting Date Desired Wages

PRIOR WORK HISTORY

Please provide a complete work history for the last 10 years (Please list most recent employers first)

Dates Name & Address Name of Supervisor Rate of Reason for
From To Of Employers & Phone Number Position Pay Leaving

EDUCATION
School Name Last Year
Completed
Course of
Study
Degree Awarded Other Training
Elementary
High School
College

If applying for a Truck Driver's job, are you 21 years of age?
Yes No  

If applying for any other position, are you 18 years of age?
Yes No  

Do you have a current Driver's License?
Yes No State: Type: Exp:  

Has your license ever been suspended?
Yes No If yes, date and reason:  

Have you ever been convicted of a criminal offense, other than a minor traffic violation, which has not subsequently been annulled?
Yes No If yes, date and reason:  

Please list all experiences, skills or qualifications which you feel would especially suit you for work with our company:

PLEASE READ CAREFULLY APPLICANT'S CERTIFICATION AND AGREEMENT
I hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge. I understand that if employed, falsified statements on this application shall be considered sufficient cause for dismissal. You are hereby authorized to investigate any statements contained on this application.

I also understand that a post-offer physical, including drug screen, are prerequisites to my employment and I hereby consent to such any exam in order to determine my ability to perform the duties of the job I am being considered for. Upon receipt of written notification from the medical facility that the employee is fit for duty, all newly hired employees will go through an orientation program that lasts for approximately two hours. Company policies and benefits will be explained and necessary paperwork will be completed.
EMPLOYMENT-AT-WILL
I understand and agree that, if hired, my employment will be at-will and may be terminated with or without notice at any time at my option or at the option of Pavement Treatments Incorporated. I understand that only a written agreement expressly to the contrary signed by me and the president of Pavement Treatments Incorporated can vary this employment-at-will policy. I agree to conform to the policies and procedures of Pavement Treatments Incorporated.
BY TYPING MY NAME BELOW, I ACKNOWLEDGE AND ACCEPT THE TERMS OF THE ABOVE STATMENTS.
APPLICANT'S ACKNOWLEDGEMENT:

REFERENCE RELEASE FORM
In connection with my application for employment at Pavement Treatments Incorporate., I hereby authorize Pavement Treatments Incorporated, Inc. to contact any of my former employers, my present employer, and any school which I attended. I consent to the release to Pavement Treatments Incorporated. of any information and records pertaining to my employment or education. I hereby release from liability all individuals and organizations who provide information to Pavement Treatments Incorporated, Inc. pursuant to this authorization. I also release from liability Pavement Treatments Incorporated, Inc. and its employees, officers, directors or agents for their acts in connection with the review and processing of my application for employment and for any acts undertaken pursuant to this authorization.

I agree that a duplicate of this form will be as effective as the original.

I am voluntarily furnishing the information below in order to assist in locating my records.
Applicant's Name:
Applicant's Maiden Name:
Any other name used by Applicant:
Applicant's Social Security Number (optional):
May we contact your present employer?
Yes No  
BY TYPING MY NAME BELOW, I ACKNOWLEDGE MY UNDERSTANDING OF THE ABOVE STATEMENTS.
APPLICANT'S SIGNATURE:


By submitting this form, you certify that the information contained in this application is complete, accurate and not misleading in any way. You authorize Pavement Treatments Incorporated and its agents to contact references provided, as well as any sources not provided in order to obtain information regarding your character and fitness for employment. Should your application be accepted, you agree to submit to the policies and procedures of Pavement Treatments Incorporated.