APPLICATION OF EMPLOYMENT

"*" indicates required fields

MM slash DD slash YYYY
Name*
Address*
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If hired, can you provide proof of U.S. citizenship or proof of your legal right to work in the U.S.?*
Are you able to perform all of the essential functions of the job for which you are applying with or without reasonable accommodation?*
If hired, are there any accommodations the company would need to provide so that you can perform all those essential functions and duties of the position being applied for?*

Employment History (Start with most recent employer)

Education

High School
Name and City of School
General Course of Study
Did you Graduate?
Last Year Completed
College
Name and City of School
General Course of Study
Did you Graduate?
Last Year Completed
Trade School
Name and City of School
General Course of Study
Did you Graduate?
Last Year Completed
Other
Name and City of School
General Course of Study
Did you Graduate?
Last Year Completed

Please provide three references, not related to you, who have knowledge of your qualifications for the job you are applying for.

If driving is a requirement of the position applied for, have you in the last 5 years been convicted of Driving Under the Influence "DUI"?*
If driving is a requirement of the position applied for, please provide:
PA License Class
Endorsements
Dr. License #
If hired, do you have a reliable means of transportation to and from work?*
I understand and agree that if I am employed, my employment will be "at-will", which means that the Company may terminate the employment relationship at any time, with or without cause and with or without notice.
I understand that the use of illegal durgs is prohibited during employment. I may be requried to successfully pass a drug and alcohol screening examination prior to being hired, and I consent to taking a drug and alchohol test at any time during my employment, should I be hired.
I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at any later date.
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AN EQUAL OPPORTUNITY EMPLOYER

ALL QUALIFIED OR QUALIFIABLE MINORITIES AND FEMALES ARE ENCOURAGED TO APPLY
Name
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EEO INFORMATION

It is the policy of Cottle's Asphalt to provide equal employment opportunity to all qualified applicants for employment without regard to race, color, religion, national origin, sex, age, veteran status or disability. Various agencies of the government require employers to invite applicants to identify themselves.

COMPLETION OF THIS FORM IS VOLUNTARY AND IN NO WAY AFFECTS THE DECISION REGARDING YOUR APPLICATION FOR EMPLOYMENT. THIS FORM IS CONFIDENTIAL AND WILL BE MAINTAINED SEPARATELY FROM YOUR APPLICATION FORM.
Gender:
Race/Ethnicity:
How did you learn of this job posting?