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13136 Lincoln Highway • Everett, PA
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APPLICATION OF EMPLOYMENT
"
*
" indicates required fields
Date
*
MM slash DD slash YYYY
Name
*
First
Last
Social Security #:
*
Phone
*
Cellphone
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
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Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
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Aruba
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Austria
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Belarus
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Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
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Bouvet Island
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Burkina Faso
Burundi
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Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
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Chile
China
Christmas Island
Cocos Islands
Colombia
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Congo, Democratic Republic of the
Cook Islands
Costa Rica
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Curaçao
Cyprus
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Denmark
Djibouti
Dominica
Dominican Republic
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El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
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Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
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Guinea-Bissau
Guyana
Haiti
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Indonesia
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Iraq
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Italy
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Jordan
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Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
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Lao People's Democratic Republic
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Mongolia
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Montserrat
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Mozambique
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Namibia
Nauru
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Nigeria
Niue
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Palestine, State of
Panama
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Peru
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Pitcairn
Poland
Portugal
Puerto Rico
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Saint Helena, Ascension and Tristan da Cunha
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Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
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Zimbabwe
Åland Islands
Country
Position applied for:
*
Date Available:
*
MM slash DD slash YYYY
Wages Desired:
*
What skills do you have or what machinery can you operate related to the job you are applying for?
*
If hired, can you provide proof of U.S. citizenship or proof of your legal right to work in the U.S.?
*
Yes
No
Are you able to perform all of the essential functions of the job for which you are applying with or without reasonable accommodation?
*
Yes
No
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?
*
Yes
No
If yes, please explain:
Employment History (Start with most recent employer)
Name/Address
Position/Type of work performed
Start Date
End Date
End Wage
Reason for Leaving
Name/Address
Position/Type of work performed
Start Date
End Date
End Wage
Reason for Leaving
Name/Address
Position/Type of work performed
Start Date
End Date
End Wage
Reason for Leaving
Name/Address
Position/Type of work performed
Start Date
End Date
End Wage
Reason for Leaving
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.
Name
Address
Phone
Relationship
Name
Address
Phone
Relationship
Name
Address
Phone
Relationship
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"?
*
YES
NO
N/A
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?
*
YES
NO
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.
Signature
*
Date
*
MM slash DD slash YYYY
AN EQUAL OPPORTUNITY EMPLOYER
ALL QUALIFIED OR QUALIFIABLE MINORITIES AND FEMALES ARE ENCOURAGED TO APPLY
Name
First
Last
Position Applied for:
Date:
MM slash DD slash YYYY
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:
Male
Female
Declined to State
Race/Ethnicity:
American Indian or Alaskan Native
Asian or Pacific Islander
Black or African American
Hispanic or Latino
White
Declined to State
How did you learn of this job posting?
Walk In
Cottle Employee Referral
PA Career Link
Newspaper Advertisement
Other
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