STOKER OILFIELD SERVICE EMPLOYMENT APPLICATION

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "STOKER OILFIELD SERVICE EMPLOYMENT APPLICATION"

Transcription

1 STOKER OILFIELD SERVICE EMPLOYMENT APPLICATION Applicant Full Name Home Phone Cell Phone Address Current Address: Number and street City State & Zip How were you referred to Company?: Employment Positions Position(s) applying for: Are you applying for: Temporary work such as summer or holiday work? [ ] Y or [ ] N Regular part-time work? [ ] Y or [ ] N Regular full-time work? [ ] Y or [ ] N What days and hours are you available for work? If applying for temporary work, when will you be available? If hired, on what date can you start working? / / Can you work on the weekends? [ ] Y or [ ] N Can you work evenings? [ ] Y or [ ] N Are you available to work overtime? [ ] Y or [ ] N Salary/ Wage per Hour desired: $

2 Personal Information: Have you ever applied to / worked for Company before? [ ] Y or [ ] N If yes, please explain (include date): Do you have any friends, relatives, or acquaintances working for Company? [ ] Y or [ ] N If yes, state name & relationship: Are you over the age of 18? (If under 18, hire is subject to verification of minimum legal age.) [ ] Y or [ ] N If hired, would you be able to present evidence of your U.S. citizenship or proof of your legal right to work in the United States? [ ] Y or [ ] N If hired, are you willing to submit to and pass a controlled substance test? [ ] Y or [ ] N Are you able to perform the essential functions of the job for which you are applying, either with / without reasonable accommodation? [ ] Y or [ ] N If no, describe the functions that cannot be performed (Note: Company complies with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. It is possible that a hire may be tested on skill/agility and may be subject to a medical examination conducted by a medical professional.) Have you ever been convicted of a criminal offense (felony or misdemeanor)? [ ] Y or [ ] N If yes, please describe the crime - state nature of the crime(s), when and where convicted and disposition of the case. (Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The date of the offense, the nature of the offense, including any significant details that affect the description of the

3 event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.) Education, Training and Experience High School: School name: School city, state, zip: Number of years completed: Did you graduate? [ ] Y or [ ] N Degree / diploma earned: College / University: School name: School city, state, zip: Number of years completed: Did you graduate? [ ] Y or [ ] N Degree / diploma earned: Vocational School: Name: City, state, zip: Number of years completed: Did you graduate? [ ] Y or [ ] N Degree / diploma? : Military: Branch: Rank in Military: Total Years of Service: Skills/duties: Related details: Additional Information Do you speak, write or understand any foreign languages? [ ] Y or [ ] N If yes, describe which languages(s) and how fluent of a speaker you consider yourself to be.

4 Do you have any other experience, training, qualifications, or skills which you feel should be brought to our attention, in the case that they make you especially suited for working with us? [ ] Y or [ ] N If yes, please explain Previous Employment Dates of Employment From To Company Position Held Supervisor Contact Number for Supervisor Position Held Responsibilities Dates of Employment From To Company Position Held Supervisor Contact Number for Supervisor Position Held

5 Responsibilities Dates of Employment From To Company Position Held Supervisor Contact Number for Supervisor Position Held Responsibilities References Give the names of three persons not related to you, whom you have known at least one year. NAME CONTACT NUMBER BUSINESS

6 AUTHORIZATION "I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from any liability for any damage that may result from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the forgoing, unless it is in writing and signed by an authorized company representative. The waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws." Signature Date

7 Consent to Investigate and Disclose Data I hereby allow Stoker Oilfield Service the right to contact and investigate my former and current employers to fully investigate my background. I also voluntarily consent to any lawful security examination and/or background checks. I authorize Stoker Oilfield Service to use any and all information acquired to make decisions regarding my employment. I understand and agree that if any adverse information is obtained or if any material facts are discovered which differ from those facts stated by me on my employment application, at my interview, or at any time prior to my commencing employment, I will not be offered the job. Furthermore, I understand and agree that if material facts are later discovered which are inconsistent with or differ from facts I furnished before taking the job, I will be disciplined, including immediate discharge without warning. Consent and Release Concerning Drug/Alcohol Testing Policy I acknowledge that I have received a copy of STOKER OILFIELD S Drug Testing Policy, that I have read and understand the policy, and that by signing this acknowledgment, I agree to adhere to the policy as a condition of my employment and/or continuing employment with STOKER OILFIELD. I also acknowledge that I am an at-will employee and that my employment may be terminated at any time for good cause, bad cause or no cause. I further acknowledge that my failure to adhere to this policy may subject me to disciplinary action, up to and including immediate termination without advance warning. I further acknowledge that I have reviewed the policy and have been given the opportunity to ask questions about the policy. I understand that my refusal to submit to a drug screen or a positive result on such a drug screen can lead to my immediate termination for work-related misconduct. Employee Signature Date

8 Acknowledgment, Consent and Release Form for STOKER OILFIELD No Handguns Policy I acknowledge that I have received, read and understand a copy of STOKER OILFIELD s No Handguns Policy. By signing this acknowledgment, I agree to adhere to the terms of the policy as a condition of my employment with STOKER OILFIELD. I also acknowledge that my employment is at will, meaning that it is of indefinite duration and may be terminated at any time, with or without advance notice, for good cause, bad cause or no cause at all. I further acknowledge that if I fail to adhere to this policy, I may be subject to disciplinary action up to and including immediate termination without prior warning. In connection with the enforcement of STOKER OILFIELD s No Handgun Policy, I give my consent to STOKER OILFIELD conducting reasonable searches for weapons prohibited by this policy. I understand that all vehicles owned or used by STOKER OILFIELD are subject to being searched at any time without my permission. I also acknowledge that I am prohibited from locking or otherwise securing any vehicle with any lock or locking device that is not supplied by STOKER OILFIELD. Acknowledgment of Receipt and Understanding of STOKER OILFIELD Policy Against Harassment in the Workplace I acknowledge that I have received a copy of STOKER OILFIELD Policy Against Harassment, that I have read and understand the policy, and that by signing this acknowledgment, I agree to adhere to the policy as a condition of my employment and/or continuing employment with STOKER OILFIELD. I acknowledge that I understand how to follow the procedures set out in this policy and that if I have any questions, I will ask for clarification. I agree to report any incident of harassment in a timely manner and I understand that there are a number of different individuals who are authorized to take my complaint and act on it appropriately. I further acknowledge that my failure to adhere to this policy may subject me to disciplinary action, up to and including immediate termination without advance warning. I have reviewed the Policy Against Harassment and have been given the opportunity to ask questions about the policy. I know that I may file a complaint of harassment or participate in an investigation without fear of retaliation. Employee Signature Date

9 Acknowledgement and Receipt of Employee Handbook Form RECORD OF RECEIPT OF EMPLOYEE HANDBOOK I acknowledge receiving the STOKER OILFIELD employee policy handbook. I CLEARLY UNDERSTAND THAT THIS POLICY HANDBOOK DOES NOT CREATE A CONTRACT FOR EMPLOYMENT WITH STOKER OILFIELD, AND THAT STOKER OILFIELD MAY CHANGE OR MODIFY THE POLICIES AND PROCEDURES IN THIS HANDBOOK AT ANY TIME, WITH OR WITHOUT PRIOR NOTICE. I HAVE READ AND UNDERSTOOD THE POLICIES OUTLINED IN THE STOKER OILFIELD HANDBOOK, AND AGREE TO BE BOUND BY THE COMPANY S RULES AND REGULATIONS DURING MY EMPLOYMENT WITH THE COMPANY. I UNDERSTAND THAT VIOLATING THE POLICIES AND RULES SET OUT IN THIS HANDBOOK MAY LEAD TO DISCIPLINE, UP TO AND INCLUDING TERMINATION. EMPLOYEE SIGNATURE DATE Revison 2 Page 25

10 Wage Deduction Agreement I understand and agree that my employer, STOKER OILFIELD may deduct money from my pay from time to time for reasons that fall into the following categories: 1. Any contributions I may make into a retirement or pension plan sponsored, controlled or managed by STOKER OILFIELD; 2. If I receive an overpayment of wages for any reason, repayment of such overpayments to STOKER OILFIELD; 3. The cost to STOKER OILFIELD of personal calls I may make on STOKER OILFIELD phones or on STOKER OILFIELD accounts; 4. The cost of repairing or replacing any STOKER OILFIELD supplies, materials, equipment, money or other property that I may damage (other than normal wear and tear), lose, fail to return or take without appropriate authorization from STOKER OILFIELD during my employment; 5. The cost of STOKER OILFIELD s uniforms if not returned; 6. If I am a salaried exempt employee who takes a full day of personal leave at my own request, the value of such leave may be deducted in eight hour increments. 7. If I take paid vacation or sick leave in advance of the date I would normally be entitled to it and I separate from STOKER OILFIELD before accruing time to cover such advance leave, the value of such leave taken in advance that is not so covered; I agree that STOKER OILFIELD may deduct money from my pay under the above circumstances, or if any of the other situations occur. Employee Signature Date

11 Motor Vehicle Report Notification & Authorization Form Date: (PLEASE PRINT OR TYPE ALL INFORMATION ON THIS FORM) Applicant/ Employee Name Applicant/Employee Address: City/State/Zip: Drivers License Number: State of Issue: Date of Birth: Social Security # I,, authorize Stoker Oilfield Service, Ltd to obtain driving records (motor vehicle reports) on my information shown above as part of the company s evaluation of my employment / insurance application. The reports may be obtained and produced by Sawyer & Associates Insurance Agency, LLC. These records will be obtained as part of the applicant or employee evaluation process, an assessment of my insurability or employability or for other permissible purposes. By signing this disclosure, I hereby authorize the company to procure such reports about me from time to time, as it deems appropriate, to evaluate my insurability or employability. Signature of Applicant / Employee

12 Employee Acknowledgment of Workers Compensation Network I have received information that tells me how to get health care under my employer s workers compensation insurance. If I am hurt on the job and live in a service area described in this information, I understand that: 1. I must choose a treating doctor from the list of doctors in the network. Or, I may ask my HMO primary care physician to agree to serve as my treating doctor. If I select my HMO primary care physician as my treating doctor, I will call Texas Mutual at (800) to notify them of my choice. 2. I must go to my treating doctor for all health care for my injury. If I need a specialist, my treating doctor will refer me. If I need emergency care, I may go anywhere. 3. The insurance carrier will pay the treating doctor and other network providers. 4. I might have to pay the bill if I get health care from someone other than a network doctor without network approval. 5. Making a false or fraudulent workers compensation claim is a crime that may result in fines and or imprisonment. Signature Date Printed Name I live at: Street Address City State Zip Code Name of Employer: STOKER OILFIELD SERVICE Name of Network: Texas Star Network Network service areas are subject to change. Call (800) if you need a network treating provider. Please indicate whether this is the: Initial Employee Notification Injury Notification (Date of Injury: / / ) DO NOT RETURN THIS FORM TO TEXAS MUTUAL INSURANCE COMPANY UNLESS REQUESTED Employee Notice of Network Requirements 2/08

13 PPE CERTIFICATION Employee Name Job Title I understand: When PPE is necessary during my work activities. What PPE I must wear (eye/face, hand, foot, head). I must inspect my PPE before and after each use. I must keep my PPE clean, sanitary, and in working order. I should never use defective PPE. I should notify my supervisor immediately of any defective PPE for replacement. Signed Date

14 Direct Deposit Authorization Form Company Name: Stoker Oilfield Service I (we) hereby authorize Stoker Oilfield Service to initiate debit entries to my (our) Checking/ Savings Account (select one) indicated below at the depository financial institution named below and to debit the same to such account. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law. Depository Name Branch City State Zip Routing Number Account Number This authorization is to remain in full force and effect until Stoker Oilfield Service has received written notification from me (or either of us) of its termination in such time and in such manner as to afford the company and the depository a reasonable opportunity to act on it. Print Name Signature Date

15

AZ PowerWash Pros LLC

AZ PowerWash Pros LLC AZ PowerWash Pros LLC Quality Service, Affordable Prices, Trained Professionals Employment Application An Equal Opportunity Employer AZ PowerWash Pros LLC is an equal opportunity employer. This application

More information

Minnetonka Assisted Living and Hospice Employment Application Please print and complete all sections.

Minnetonka Assisted Living and Hospice Employment Application Please print and complete all sections. Minnetonka Assisted Living and Hospice Employment Application Please print and complete all sections. Full Current Home Phone #: Other Phone #: Position applying for (circle one): Home Health Aide Certified

More information

Please Print in Ink or Type NOTE: Some positions may require a TB Test and/or Tetanus Shot. Present Address -

Please Print in Ink or Type NOTE: Some positions may require a TB Test and/or Tetanus Shot. Present Address - An Equal Opportunity Employer Where did you learn about our Job Openings? Zoo Employment Web Page Family Member Friend College Employment Web Page College Job Fair Craig s List Radio Announcement Zoo News

More information

AN EQUAL OPPORTUNITY EMPLOYMENT APPLICATION

AN EQUAL OPPORTUNITY EMPLOYMENT APPLICATION AN EQUAL OPPORTUNITY EMPLOYMENT APPLICATION Please Print Date: Name: Last First Middle Home Phone: Cell Phone: Social Security #: Present Email : No. Street City State Zip Mailing (If Different) No. Street

More information

APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT FRONTRUNNERS NEW BALANCE STORES LOS ANGELES 2828 Wilshire Blvd Santa Monica CA 90403 APPLICATION FOR EMPLOYMENT BACKGROUND CHECKS Frontrunners/NBLA is concerned about violence in the workplace, falsified

More information

Employment Application

Employment Application Employment Application Please Print Date Home phone ( ) Secondary phone ( ) Social Security Number Present Permanent (If different from above) Employment Desired Position applying for What days and hours

More information

APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT IMPORTANT: It is the policy of the Village of Plymouth to provide equal opportunity with regard to all terms and conditions of employment. The Village complies with federal and state laws prohibiting discrimination

More information

Telephone Long Distance Digital Cable TV High Speed Internet Networking APPLICATION FOR EMPLOYMENT. Last First Middle. Number Street City State Zip

Telephone Long Distance Digital Cable TV High Speed Internet Networking APPLICATION FOR EMPLOYMENT. Last First Middle. Number Street City State Zip 21668 Double Arch Road PO Box 29 Staunton, IL 62088 Phone (618) 635-3214 Fax (618) 635-7213 www.gomadison.com Telephone Long Distance Digital Cable TV High Speed Internet Networking APPLICATION FOR EMPLOYMENT

More information

Application for Employment

Application for Employment Application for Employment GENERAL INFORMATION (Please Print) Name: Telephone No.: LAST FIRST MIDDLE Email Address: Present Address: Position Desired: STREET CITY STATE ZIP Pay Desired: If hired, can you

More information

Synergy Paintball Challenge, LLC Employment Application Form (Please Print)

Synergy Paintball Challenge, LLC Employment Application Form (Please Print) Synergy Paintball Challenge, LLC Employment Application Form (Please Print) Applicant Name: Home Phone: Cell Phone: Email Address: Current Address: City: State & Zip: How were you referred to Synergy Paintball

More information

Have you ever been employed by The Texas Department of Criminal Justice?

Have you ever been employed by The Texas Department of Criminal Justice? PRE-EMPLOYMENT APPLICATION is an equal opportunity employer and will consider all applicants for all positions equally without regard to their race, sex, age, color, religion, national origin, veteran

More information

Employment Application

Employment Application Employment Application Please complete this application as completely and accurately as possible PERSONAL INFORMATION Today s Date Name: Last First Middle Social Security Number Address Home Telephone

More information

PROJECT 375 EMPLOYMENT APPLICATION

PROJECT 375 EMPLOYMENT APPLICATION PROJECT 375 EMPLOYMENT APPLICATION Thank you for your interest in PROJECT 375. Our application process is built to ensure the very best experience for you the applicant. Please follow these instructions

More information

HOW TO APPLY FOR A JOB AT SKY ZONE RIVERSIDE

HOW TO APPLY FOR A JOB AT SKY ZONE RIVERSIDE HOW TO APPLY FOR A JOB AT SKY ZONE RIVERSIDE Thank you for your interest in employment at Sky Zone Riverside! We are always seeking quality candidates to fulfill roles as Cashier, Court Monitor, Party

More information

TODD S ON THE GO, LLC 260 13 th Street Marion, IA 52302 PHONE: (319) 892-0136

TODD S ON THE GO, LLC 260 13 th Street Marion, IA 52302 PHONE: (319) 892-0136 TODD S ON THE GO, LLC 260 13 th Street Marion, IA 52302 PHONE: (319) 892-0136 Position Applied for: Date: dd s On The Go, LLC considers all applicants for employment without regard to race, color, religion,

More information

New Hire Submission and Return Receipt PLEASE SUBMIT FORMS TO: SERVICE@ADVANCEDPEO.COM OR FAX 1-866-611-9598

New Hire Submission and Return Receipt PLEASE SUBMIT FORMS TO: SERVICE@ADVANCEDPEO.COM OR FAX 1-866-611-9598 1933 E EDGEWOOD DR SUITE 102 LAKELAND, FL 33803 1-877-518-2881 WWW.ADVANCEDPEO.COM New Hire Submission and Return Receipt PLEASE SUBMIT FORMS TO: SERVICE@ADVANCEDPEO.COM OR FAX 1-866-611-9598 Notice to

More information

Mississippi Security Police Inc. 3003 Pascagoula Street Pascagoula, MS 39567 228.762.0661 228.769.5583 fax

Mississippi Security Police Inc. 3003 Pascagoula Street Pascagoula, MS 39567 228.762.0661 228.769.5583 fax Mississippi Security Police Inc. 3003 Pascagoula Street Pascagoula, MS 39567 228.762.0661 228.769.5583 fax Dear Applicant: Please comply with the following requirements. Please review qualifications and

More information

EMPLOYMENT APPLICATION

EMPLOYMENT APPLICATION 301 Church Avenue, Knoxville TN 37915 APPLICANT INSTRUCTIONS: If you need assistance filling out this application form please contact KAT at (865) 215-7800. 1. Please read "APPLICANT NOTE" below. 2. Complete

More information

Application for Employment

Application for Employment Application for Employment NETCARE CORPORATION 199 South Central Avenue Columbus, OH 43223 (614) 274-9500 Applicants are considered for all positions in accordance with statutes and regulations concerning

More information

INSTRUCTIONS FOR EMPLOYMENT APPLICATIONS

INSTRUCTIONS FOR EMPLOYMENT APPLICATIONS INSTRUCTIONS FOR EMPLOYMENT APPLICATIONS In order to comply with Federal and State Government requirements, a complete file on all employees is required. The employee file must consist of a completed Employment

More information

An Equal Opportunity Employer

An Equal Opportunity Employer An Equal Opportunity Employer Federal, State and Local Laws prohibit discrimination because of race, color, sex, age, national origin, ancestry, handicap or veteran status. APPLICATION FOR EMPLOYMENT (Please

More information

EMPLOYMENT APPLICATION

EMPLOYMENT APPLICATION EMPLOYMENT APPLICATION Equal Opportunity Employer It is our policy to abide by all Federal and State laws prohibiting employment discrimination solely on the basis of a person s race, color, creed, national

More information

Atlanta Location 3701 Presidential Parkway Atlanta, GA 30340 P: 678.720.9882 F: 678.720.9885

Atlanta Location 3701 Presidential Parkway Atlanta, GA 30340 P: 678.720.9882 F: 678.720.9885 Atlanta Location 3701 Presidential Parkway Atlanta, GA 30340 P: 678.720.9882 F: 678.720.9885 Kennesaw Location 2801 George Busbee Parkway Kennesaw, GA 30144 P: 770.545.6227 F: 770.545.6229 Email: info@ssclimbing.com

More information

Daily Deals Food Outlet APPLICATION FOR EMPLOYMENT

Daily Deals Food Outlet APPLICATION FOR EMPLOYMENT APPLICATION FOR EMPLOYMENT WE ARE AN EQUAL OPPORTUNITY EMPLOYER. does not discriminate in employment opportunities or practices on the basis of race, color, religion, sex, national origin, age, height,

More information

CLIPPER COURIER LOGISTICS SUMMARY FOR INDEPENDENT CONTRACTORS

CLIPPER COURIER LOGISTICS SUMMARY FOR INDEPENDENT CONTRACTORS CLIPPER COURIER LOGISTICS SUMMARY FOR INDEPENDENT CONTRACTORS CLIPPER COURIER LOGISTICS, INC. REQUIREMENTS: 1. INSURANCE COVERAGES MUST MEET OR EXCEED THESE MINIMUMS AND COPIES OF THE DECLARATION PAGE

More information

Please contact Human Resources at (419)562-3011 if you need a reasonable accommodation to complete this application.

Please contact Human Resources at (419)562-3011 if you need a reasonable accommodation to complete this application. United Ohio Insurance Company is an equal opportunity employer. United Ohio Insurance Company will comply with any legal obligation to provide reasonable accommodation to otherwise qualified individuals

More information

SECTION 1 TO BE COMPLETED BY EMPLOYEE S SUPERVISOR/MANAGER

SECTION 1 TO BE COMPLETED BY EMPLOYEE S SUPERVISOR/MANAGER SECTION 1 TO BE COMPLETED BY EMPLOYEE S SUPERVISOR/MANAGER Client Company: Client Location: Dept. Name or Number: Date of Hire: Job Title: Workers Comp Class Code: Employee ID: CLASSIFICATION If you need

More information

First Middle Last. Number and Street City State Zip Code Home Telephone # Work Telephone #

First Middle Last. Number and Street City State Zip Code Home Telephone # Work Telephone # EMPLOYMENT APPLICATION Fire Department City of Sterling, Colorado 421 N. 4 th St., P.O. Box 4000 Sterling, CO 80751-0400 Phone (970) 522-9700 FAX (970)521-0632 www.sterlingcolo.com An Equal Opportunity

More information

Dietert Center. 451 Guadalupe St., Ste 101, Kerrville, Texas Employment Application Form

Dietert Center. 451 Guadalupe St., Ste 101, Kerrville, Texas Employment Application Form 451 Guadalupe St., Ste 101, Kerrville, Texas 78028 Employment Application Form PLEASE PRINT ALL INFORMATION REQUESTED EXCEPT SIGNATURE PLEASE COMPLETE ALL PAGES. DATE Name Last First Middle Maiden Present

More information

Application for Employment

Application for Employment ParaBasic Ambulance Service Member of the American Ambulance Association (Mailing Address) PO BOX 5, ANDREWS SC 29510 145 W. Balsam Street, Andrews SC 29510 204 Short Street, Kingstree SC 29556 4955 Hwy

More information

Ohiopyle Prints, Inc.

Ohiopyle Prints, Inc. Ohiopyle Prints, Inc. 410 Dinner Bell Road Ohiopyle, PA 15470 724-329-4652 2016 STUDENT SUMMER WORK PROGRAM Starting Pay $7.25 / hr $50 Attendance Bonus Plan Must be 16 years or older and have a valid

More information

First Name: Middle Initail: Last Name: Street No. & Name: Apt# (if any): City: State: Postal Code: Home Phone w/area code: Mobile Phone:

First Name: Middle Initail: Last Name: Street No. & Name: Apt# (if any): City: State: Postal Code: Home Phone w/area code: Mobile Phone: Employment Application Advanced Security Services Inc. 95 Plaistow Road Plaistow, NH 03865 PH: 603-382-1300 FX: 603-382-0030 info@advancedsecurityservices.net Personal Information First Name: Middle Initail:

More information

WYOMING RENTS, LLC APPLICATION FOR EMPLOYMENT DRUG AND ALCOHOL-FREE WORK PLACE

WYOMING RENTS, LLC APPLICATION FOR EMPLOYMENT DRUG AND ALCOHOL-FREE WORK PLACE WYOMING RENTS, LLC APPLICATION FOR EMPLOYMENT DRUG AND ALCOHOL-FREE WORK PLACE People at this company want a safe and healthy place to work. Illegal drugs are wrong! There is no place here for them or

More information

Name: Last First MI. Address: Street, PO Box City State Zip. Have you ever been known by any other name? Yes. Driver's License Number: State: Expires:

Name: Last First MI. Address: Street, PO Box City State Zip. Have you ever been known by any other name? Yes. Driver's License Number: State: Expires: APPLICATION FOR EMPLOYMENT: PLEASE PRINT Arizona Health Care Contract Management Services, Inc A Human Services Management Corporation 110 W. Camelback Road, Ste. 200 Phoenix, Arizona 85013 (602) 230-2222

More information

! EMPLOYMENT APPLICATION

! EMPLOYMENT APPLICATION ! EMPLOYMENT APPLICATION The Lucky Star and Feather Warrior Casinos are Equal Opportunity Employers and will not discriminate against an applicant or employee on any grounds protected under federal, state,

More information

Memphis Recovery Centers, Inc.

Memphis Recovery Centers, Inc. Memphis Recovery Centers, Inc. Special Instructions for Pre-Employment Application Read this document in full. Initial each item indicated. Memphis Recovery Centers is concerned with hiring the most qualified

More information

APPLICATION INSTRUCTIONS BASIC PERSONAL INFORMATION

APPLICATION INSTRUCTIONS BASIC PERSONAL INFORMATION APPLICATION INSTRUCTIONS Information on this application will be used to judge your qualifications and evaluate your education for the position that you are applying for. Please read all of the questions

More information

Dynamic Physical Therapy & Rehabilitation Center: Employee Records Update Packet Page 1 of 16 Revised: October 6, 2003

Dynamic Physical Therapy & Rehabilitation Center: Employee Records Update Packet Page 1 of 16 Revised: October 6, 2003 Dynamic Physical Therapy & Rehabilitation Center: Employee Records Update Packet Page 1 of 16 Revised: October 6, 2003 The following Employee Records Update Packet is information that is required by our

More information

CHEM CARRIERS 1237 HIGHWAY 75 SUNSHINE, LA 70780

CHEM CARRIERS 1237 HIGHWAY 75 SUNSHINE, LA 70780 Application for Employment and Background Check for Previous 7 Years (attach additional pages if necessary) CHEM CARRIERS As part of the application process, Chem Carriers and NationsCheck Inc. may conduct

More information

CITY OF CLAWSON FIRE DEPARTMENT

CITY OF CLAWSON FIRE DEPARTMENT PERSONAL: Name: (Last) (First) (Middle) Date of Application: Address: Phone No.: Length of Time: (Number and Street) (City, State and Zip) (six months Req'd) (Home) (Work) (Cell) Social Security No.: Driver's

More information

LONE ROCK TIMBER MANAGEMENT COMPANY LONE ROCK LOGGING COMPANY 2323 OLD HIGHWAY 99 SOUTH P.O. BOX 1127 ROSEBURG, OR 97470 PH.

LONE ROCK TIMBER MANAGEMENT COMPANY LONE ROCK LOGGING COMPANY 2323 OLD HIGHWAY 99 SOUTH P.O. BOX 1127 ROSEBURG, OR 97470 PH. LONE ROCK TIMBER MANAGEMENT COMPANY LONE ROCK LOGGING COMPANY 2323 OLD HIGHWAY 99 SOUTH P.O. BOX 1127 ROSEBURG, OR 97470 PH. (541) 673-0141 APPLICATION FOR EMPLOYMENT Applicants will receive consideration

More information

Application Checklist

Application Checklist Application Checklist POSITION APPLIED FOR: Indian Preference shall not be claimed without proof. Submitted applications without copies of verification documents, unanswered questions, omitted dates, omitted

More information

EMPLOYMENT APPLICATION (AN EQUAL OPPORTUNITY EMPLOYER)

EMPLOYMENT APPLICATION (AN EQUAL OPPORTUNITY EMPLOYER) : EMPLOYMENT APPLICATION (AN EQUAL OPPORTUNITY EMPLOYER) 85 C BAKERY CAFE is an equal employment opportunity employer. We comply with federal state and local laws regarding equal employment opportunity.

More information

EMPLOYMENT APPLICATION We are an Equal Opportunity Employer

EMPLOYMENT APPLICATION We are an Equal Opportunity Employer EMPLOYMENT APPLICATION We are an Equal Opportunity Employer Please print in ink. You must complete entire application. Date: Applicant Information Name (first, middle, last) (street, city, state, zip code)

More information

Human Resources Department

Human Resources Department Human Resources Department APPLICANT NAME: JOB TITLE: TO: FROM: SUBJECT: APPLICANTS FOR EMPLOYMENT WITH THE CITY OF CLINTON THE HUMAN RESOURCES STAFF APPLICATION PROCESS The application process with the

More information

EMPLOYMENT APPLICATION

EMPLOYMENT APPLICATION Family Care Network, Inc. 13967 Farmington Road Livonia, Ml 48154 (734)266-1421 Fax (734)266-1422 EMPLOYMENT APPLICATION PERSONAL DATA LAST NAME FIRST MIDDLE ADDRESS NUMBER & STREET CITY STATE ZIP SOCIAL

More information

San Antonio AIDS Foundation Application for Employment

San Antonio AIDS Foundation Application for Employment San Antonio AIDS Foundation Application for Employment The San Antonio AIDS Foundation is an affirmative action and equal opportunity employer. All qualified applicants will receive consideration for employment

More information

Volunteer Driver Application Form

Volunteer Driver Application Form Road to Recovery Volunteer Driver Application Form Please Print Name: Street Address: City State Zip: Other Address Information/ Email: Home Phone: Work Phone: Date of Birth: Occupation: Emergency Contact

More information

WE REQUIRE BACKGROUND CHECKS AND DRUG TESTING FOR MOST POSITIONS. PLEASE INITIAL TO THE PERMISSION TO COMPLETE A BACKGROUND CHECK AND DRUG TEST:

WE REQUIRE BACKGROUND CHECKS AND DRUG TESTING FOR MOST POSITIONS. PLEASE INITIAL TO THE PERMISSION TO COMPLETE A BACKGROUND CHECK AND DRUG TEST: Mild to Wild Rafting and Jeep Trail Tours, Inc. 50 Animas View Dr. Durango, CO 81301 800-567-6745 www.mild2wildrafting.com Fax: 970-382-0545 APPLICATION FOR EMPLOYMENT DATE OF APPLICATION: WE REQUIRE BACKGROUND

More information

APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT APPLICATION FOR EMPLOYMENT The Town of East Hampton is an equal opportunity employer and does not discriminate on the basis of race, religion, color, national origin, age, sex, gender, disability or any

More information

HUMBOLDT COUNTY EMPLOYMENT APPLICATION

HUMBOLDT COUNTY EMPLOYMENT APPLICATION Name Address HUMBOLDT COUNTY EMPLOYMENT APPLICATION An Equal Opportunity If you believe you require an accommodation during the selection process, please contact us to make appropriate arrangements. Date

More information

APPLICANT INSTRUCTIONS

APPLICANT INSTRUCTIONS APPLICANT INSTRUCTIONS Thank you for your interest in employment with our Company. We appreciate your application, and look forward to the possibility of you joining our team. This sheet is for your information.

More information

AMERICAN BUILDERS SUPPLY Employment Application

AMERICAN BUILDERS SUPPLY Employment Application AMERICAN BUILDERS SUPPLY Employment Application APPLICANT INFORMATION Last Name First M.I. Date Street Apartment/Unit # City State ZIP Phone E-mail Date Available Social Security No. Position Applied for

More information

APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT APPLICATION FOR EMPLOYMENT An Equal Opportunity Employer All applicants are considered without regard to race, color, gender, religion, national origin, age, marital or veteran status, mental or physical

More information

MONTGOMERY YMCA APPLICATION FOR EMPLOYMENT

MONTGOMERY YMCA APPLICATION FOR EMPLOYMENT RETURN TO BRANCH: MONTGOMERY YMCA APPLICATION FOR EMPLOYMENT YMCA Mission To put Christian principles into practice through programs that build a healthy body, mind and spirit for all. Equal Opportunity

More information

Application for Employment

Application for Employment Application for Employment Northeast Youth & Family Services (NYFS) appreciates your interest in our organization and wishes to assure you that we are sincerely interested in your qualifications. A clear

More information

THE REHABILITATION CENTER 1439 BUFFALO STREET OLEAN, NEW YORK 14760 APPLICATION FOR EMPLOYMENT

THE REHABILITATION CENTER 1439 BUFFALO STREET OLEAN, NEW YORK 14760 APPLICATION FOR EMPLOYMENT THE REHABILITATION CENTER 1439 BUFFALO STREET OLEAN, NEW YORK 14760 APPLICATION FOR EMPLOYMENT APPLICANTS ARE CONSIDERED FOR ALL POSITIONS WITHOUT REGARD TO RACE, COLOR, RELIGION, SEX, NATIONAL ORIGIN,

More information

Bennett County Hospital and Nursing Home

Bennett County Hospital and Nursing Home Bennett County Hospital and Nursing Home EMPLOYMENT APPLICATION Name: Position(s) Applying For: APPLICANT INFORMATION Bennett County Hospital and Nursing Home EMPLOYMENT APPLICATION Last Name First M.I.

More information

Employee Enrollment Package WELCO ONE, LLC. dba Worksite Employee Leasing

Employee Enrollment Package WELCO ONE, LLC. dba Worksite Employee Leasing Employee Enrollment Package WELCO ONE, LLC. dba Worksite Employee Leasing An Equal Opportunity Employer We adhere to a policy of making employment decisions without regard to race, color, age, sex, religion,

More information

Once you have read this page, please remove it from the application and keep for your personal reference.

Once you have read this page, please remove it from the application and keep for your personal reference. WELCOME TO NATIONAL CENTER ON INSTITUTIONS AND ALTERNATIVES (NCIA) As you consider a career with NCIA and to gain a better understanding of our agency, please take few minutes to read the following information.

More information

APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT APPLICATION FOR EMPLOYMENT Dallas Summer Musicals/DSM Management Group is committed to providing equal opportunity in all employment practices, including but not limited to selection, hiring, promotion,

More information

BASKETBALL COURT MONITOR AND PROGRAMMER

BASKETBALL COURT MONITOR AND PROGRAMMER Village of South Orange Department of Recreation & Cultural Affairs 5 Mead Street South Orange, NJ 07079 (973) 378-7754 General Statement of Duties BASKETBALL COURT MONITOR AND PROGRAMMER The outdoor basketball

More information

APPLICATION FOR EMPLOYMENT DOT APPLICATION FOR TRUCK DRIVERS

APPLICATION FOR EMPLOYMENT DOT APPLICATION FOR TRUCK DRIVERS APPLICATION FOR EMPLOYMENT DOT APPLICATION FOR TRUCK DRIVERS Motor Carrier: Address: City: State: Zip: Information required on this form complies with U.S. Department of Transportation Regulations 49CFR

More information

Michael Gayoso, Jr. Office of the County Attorney TH

Michael Gayoso, Jr. Office of the County Attorney TH Michael Gayoso, Jr. Office of the County Attorney TH 11 Judicial District/Crawford County, Kansas DIVERSION PROGRAM -- DRIVING UNDER THE INFLUENCE Pursuant to K.S.A. 22-2906 et seq. the Crawford County

More information

APPLICATION FOR BENEFITS LAW ENFORCEMENT OFFICERS AND FIRE FIGHTERS DISABILITY BENEFITS TRUST FUND

APPLICATION FOR BENEFITS LAW ENFORCEMENT OFFICERS AND FIRE FIGHTERS DISABILITY BENEFITS TRUST FUND EXHIBIT A M S Attorney General s Office Use Only: Application #: Receipt Date: G Approved G Disapproved Claim type: G Law Enforcement Officer G Fire Fighter STOP. Please read the fund policies and procedures

More information

SOUTH JERSEY PORT CORPORATION. Application For Employment. P.O. Box 129. Camden, New Jersey 08101. An Equal Opportunity Employer. Name.

SOUTH JERSEY PORT CORPORATION. Application For Employment. P.O. Box 129. Camden, New Jersey 08101. An Equal Opportunity Employer. Name. SOUTH JERSEY PORT CORPORATION P.O. Box 129. Camden, New Jersey 08101 Application For Employment An Equal Opportunity Employer NOTE: This application form was designed for use by persons applying for various

More information

Group/Association - Total and Permanent Disability / Waiver of Premium

Group/Association - Total and Permanent Disability / Waiver of Premium Group/Association - Total and Permanent Disability / Waiver of Premium Connecticut General Life Insurance Company Life Insurance Company of rth America CIGNA Life Insurance Company of New York FRAUD WARNING:

More information

City of Terrell Hills 5100 North New Braunfels Avenue San Antonio, Texas 78209 210-824-7401

City of Terrell Hills 5100 North New Braunfels Avenue San Antonio, Texas 78209 210-824-7401 To All Applicants: In order for the City of Terrell Hills to process this application, it must be complete. All lines must be filled in. If something does not apply to you, then write N/A in that blank.

More information

EMPLOYMENT APPLICATION. Get Involved

EMPLOYMENT APPLICATION. Get Involved EMPLOYMENT APPLICATION Get Involved To be completed by a potential employee. Please complete this application by typing or printing in ink. INCOMPLETE or UNSIGNED applications will not be considered. Email

More information

Address: Street. If you are under 18 years of age, do you have a work permit? Yes If you have ever worked under another name, please identify:

Address: Street. If you are under 18 years of age, do you have a work permit? Yes If you have ever worked under another name, please identify: APPLICATION FOR EMPLOYMENT Miles farmers market 28560 Miles Road, Solon, OH 44139 ph 440.248.5222 toll free 800.646.4537 fx 440.248.7518 www.milesfarmersmarket.com Thank you for your interest in applying

More information

EMPLOYMENT APPLICATION APPLICANT INFORMATION Last Name First Name Middle Initial Date Street Address Apartment/Unit # City State Zip

EMPLOYMENT APPLICATION APPLICANT INFORMATION Last Name First Name Middle Initial Date Street Address Apartment/Unit # City State Zip 1077 Route 119 Highway North Indiana, PA 15701 Phone: 724-465-9399 Fax: 724-465-9829 www.forceincorporated.com Indiana, PA Barnesville, OH Waynesburg, PA Butler, PA EMPLOYMENT APPLICATION APPLICANT INFORMATION

More information

INSTRUCTIONAL, PROFESSIONAL OR ADMINISTRATIVE STAFF APPLICATION

INSTRUCTIONAL, PROFESSIONAL OR ADMINISTRATIVE STAFF APPLICATION INSTRUCTIONAL, PROFESSIONAL OR ADMINISTRATIVE STAFF APPLICATION Position for which you are applying Please type or print clearly in ink. Complete all sections even if enclosing a resume. Please submit

More information

Application Information Please read the following before completing your application

Application Information Please read the following before completing your application Application Information Please read the following before completing your application Employment Policy The City of Suwanee is an Equal Opportunity Employer and does not discriminate on the basis of race,

More information

100 West Cypress Creek Road Suite 850 Fort Lauderdale, Florida PHONE: FAX

100 West Cypress Creek Road Suite 850 Fort Lauderdale, Florida PHONE: FAX 100 West Cypress Creek Road Suite 850 Fort Lauderdale, Florida 33309 PHONE: 954-876-0033 FAX 954-876-0062 EMPLOYMENT APPLICATION An Equal Opportunity Employer and a Drug Free Workplace The Broward MPO

More information

Current Home Address City State Zip How long at this address? Previous Address (If less than 4 years above.) City State Zip How long at this address?

Current Home Address City State Zip How long at this address? Previous Address (If less than 4 years above.) City State Zip How long at this address? EMPLOYMENT APPLICATION Federal, state and local laws prohibit discrimination based on race, color, sex, religion, national origin, age, ancestry, disability or marital status. MLG NAI MLG Commercial /

More information

DENVER COMMUNITY SCHOOL DISTRICT Non-Certified Application for Employment

DENVER COMMUNITY SCHOOL DISTRICT Non-Certified Application for Employment DENVER COMMUNITY SCHOOL DISTRICT Non-Certified Application for Employment FULL NAME OTHER NAME(S) Current Address LAST FIRST MIDDLE INITIAL DATE PLEASE PROVIDE ANY OTHER NAMES YOU HAVE USED AT ANY TIME

More information

THREE RIVERS COMMUNITY COLLEGE PERSONNEL REGULATION

THREE RIVERS COMMUNITY COLLEGE PERSONNEL REGULATION Last Revision: 03/30/10 Page 1 of 7 Workers Compensation The purpose of this regulation is to ensure that employees of Three Rivers Community College injured within the course and scope of their employment

More information

APPLICATION FOR PRINCIPAL FELLOWSHIP

APPLICATION FOR PRINCIPAL FELLOWSHIP APPLICATION FOR PRINCIPAL FELLOWSHIP Thank you for your interest in applying for The Principal Fellowship for 2015-16. Below you will find a brief overview of the selection process and the necessary application

More information

EMPLOYMENT APPLICATION

EMPLOYMENT APPLICATION EMPLOYMENT APPLICATION Please answer all of the questions completely and accurately and indicate the position for which you wish to be considered. This application will only be considered for the position

More information

Application for Employment Eagle Fire Department An Equal Opportunity Employer

Application for Employment Eagle Fire Department An Equal Opportunity Employer Application for Employment Eagle Fire Department An Equal Opportunity Employer To be considered an applicant, you must complete this form. A resume may also be attached See job announcement for application

More information

Office of the Attorney General Attn: Personnel The Capitol - PL01 Tallahassee, FL 32399-1050

Office of the Attorney General Attn: Personnel The Capitol - PL01 Tallahassee, FL 32399-1050 A State of Florida Job Application Form is contained on the next four pages. You may print the form, complete the information and mail to the Office of the Attorney General. Please include the position

More information

McAlester Fire Recruit

McAlester Fire Recruit McAlester Fire Recruit PLEASE RETURN the following to the Human Resources office: Job Application Copy of High School Diploma or Equivalency Copy of Driver s License Waiver and Release Form NOTE: Failure

More information

LEAGUE CITY VOLUNTEER FIRE DEPARTMENT

LEAGUE CITY VOLUNTEER FIRE DEPARTMENT LEAGUE CITY VOLUNTEER FIRE DEPARTMENT 555 W. Walker Phone 281-554-1465 Dear Applicant: Thank you for your interest in becoming a member of the League City Volunteer Fire Department. Our success as a community

More information

FRUITA POLICE DEPARTMENT

FRUITA POLICE DEPARTMENT FRUITA POLICE DEPARTMENT Personal History Form for Police Officer Applicants Personal Full Legal Last First Middle Name Sex Height Weight Hair Eyes Social Security Number Driver s License No. State Expiration

More information

APPLICATION FOR EMPLOYMENT Please TYPE or print using BLACK or BLUE ink

APPLICATION FOR EMPLOYMENT Please TYPE or print using BLACK or BLUE ink Name: First Last 11878 Avenue of Industry San Diego, CA 92128 Telephone: (858) 675-4200 Fax: (858) 675-9241 APPLICATION FOR EMPLOYMENT Please TYPE or print using BLACK or BLUE ink Date Application Completed:

More information

Disclosure and Authorization to Obtain Information

Disclosure and Authorization to Obtain Information Disclosure and Authorization to Obtain Information In connection with my suitability for employment with, (herein Company ) or if employed, I understand that prior to or at the time after my employment

More information

HOW TO COMPLETE THE EMPLOYMENT APPLICATION Thank you for your interest in employment with the Tohono O odham Nation!

HOW TO COMPLETE THE EMPLOYMENT APPLICATION Thank you for your interest in employment with the Tohono O odham Nation! Tohono O odham Nation Executive Branch HUMAN RESOURCES OFFICE P.O. Box 837, Sells Arizona 85634 Phone: (520) 383-6540 Fax: (520) 383-4676 (520) 361-3766, (520) 362-3766, Tucson Line: (520) 623-5783 Website:

More information

Please follow these instructions when completing this application: 1. Please print legibly in ink.

Please follow these instructions when completing this application: 1. Please print legibly in ink. 525 Palisade Avenue Cliffside Park, NJ 0701 (201) 313-2064 Employment Application The Borough of Cliffside Park EMS Department is an Equal Opportunity Employer Operating under the New Jersey Department

More information

Employment Application

Employment Application Employment Application We appreciate the opportunity to review your qualifications for employment with the company. So that we can thoroughly consider your special skills and abilities, we would appreciate

More information

KenCom Public Safety Dispatch 9-1-1 Telecommunicator (Full-time)

KenCom Public Safety Dispatch 9-1-1 Telecommunicator (Full-time) KenCom Public Safety Dispatch 9-1-1 Telecommunicator (Full-time) KenCom Public Safety Dispatch is a consolidated emergency communications center located in Kendall County. KenCom is a 24 hour, 7 day a

More information

Please answer all questions which apply to you and mark those that do not apply with N/A. LAST NAME FIRST NAME MIDDLE NAME

Please answer all questions which apply to you and mark those that do not apply with N/A. LAST NAME FIRST NAME MIDDLE NAME CRIMINAL JUSTICE INSTITUTE University of Arkansas System 26 Corporate Hill Dr Little Rock, Arkansas 72205 (501) 570-8000 APPLICATION FOR EMPLOYMENT The Criminal Justice Institute is an Equal Opportunity/Affirmative

More information

GREENRU A CHAMNESS COMPANY

GREENRU A CHAMNESS COMPANY 2255 LITTLE WALL LAKE ROAD BLAIRSBURG, IA 50034 515-325- 6133 515-325- 6134 (F) WWW.GREENRU.ORG GREENRU A CHAMNESS COMPANY Dear Applicant: Per FMCSR 391.21(d) Before an application is submitted, the motor

More information

All Star Adventures Employment Application

All Star Adventures Employment Application All Star Adventures Employment Application Is this the right job for you? Below are a few of the requirements that you would be expected to meet if you decide to continue with the application process:

More information

Police Officer Application

Police Officer Application Town of Lowell Lowell Police Department 1333 East Commercial Avenue Lowell, Indiana, 46356 Police Officer Application TO: Instructions: All Lowell Police Officer Applicants (PLEASE READ CAREFULLY) Please

More information

HIGH SCHOOL DIPLOMA OR GED REQUIRED. Application for Employment

HIGH SCHOOL DIPLOMA OR GED REQUIRED. Application for Employment HIGH SCHOOL DIPLOMA OR GED REQUIRED. THIS APPLICATION MUST BE COMPLETED IN ITS ENTIRETY AND SIGNED OR WILL NOT BE ACCEPTED. RESUMES MAY BE ATTACHED, BUT WORK HISTORY INFORMATION MUST BE COMPLETED. 3131

More information

Police Officer Candidate Application Cover

Police Officer Candidate Application Cover Police Officer Candidate Application Cover 1. Application 2. Formal Interview 3. Physical Ability and Written Test a. Obstacle Course b. Rescue Simulation c. Disabled Vehicle Push d. 1.5 Mile Run 4. Background

More information

APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT APPLICATION FOR EMPLOYMENT SEABORNE AIRLINES, (hereinafter Employer or The Company ) is an equal opportunity employer and does not unlawfully discriminate in employment. No question on this application

More information

Driver s Application for Employment Applicants will be tested for illegal drugs

Driver s Application for Employment Applicants will be tested for illegal drugs Driver s Application for Employment Applicants will be tested for illegal drugs 10367 Randleman Road Randleman, NC 27317 (336) 498-9000 FAX: (336) 498-2204. ApplicantName: Date: _ In compliance with Federal

More information

Uniform Employment Application for Nurse Aide Staff

Uniform Employment Application for Nurse Aide Staff Uniform Employment Application for Nurse Aide Staff This application form is required by Title 63 O.S. Section 1-1950.4 of state law and by the Oklahoma State Board of Health Rules OAC 310-2-15-3. This

More information

ADP TOTALSOURCE MODEL EMPLOYMENT APPLICATION

ADP TOTALSOURCE MODEL EMPLOYMENT APPLICATION ADP TOTALSOURCE MODEL EMPLOYMENT APPLICATION INSTRUCTIONS: Please detach this instruction page prior to giving the application form to the applicant. Please note that we generally advise against making

More information