Application of Employment - Cottle's Asphalt Maintenance Inc

Date *

Name *

First

Last

Social Security # *

Phone *

Cellphone *

Address *

City/State/Zip *

Position Applied For *

Date Available *

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

Educational Background *

**High School, College, Other. Please list Name, Location, years completed, and if graduated. Also, list course of study.

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

**Please list Name, Address, Phone, and 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, and Dr. License #: *

If hired, do you have a reliable means of transportation to and from work? *

Yes
No

APPLICANT STATEMENT

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.

Name *

First

Last

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

Date *

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:

Definitions of Ethnicity Categories

How did you learn of this job posting?

If Newspaper Advertisement, Please give Name of Newspaper

If Other, Please explain

Call Us:

Email Us:

8:00 AM - 4:30 PM