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Employment Application
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Name
*
First
Middle
Last
Address
*
Address Line 1
Address Line 2
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State
Zip Code
Phone
*
E-mail
*
Are you a citizen of the United States?
*
Yes
No
Are you authorized to work in the U.S.?
*
Yes
No
Social Security No.
*
Are you 18 years of age or older?
*
Yes
No
Have you ever been convicted of a felony?
*
Yes
No
Please explain:
*
Employment Desired
Position Applied for:
*
Date Available:
*
Salary Desired:
*
Have you ever worked for this company?
*
Yes
No
If yes, when?
*
Supervisor’s Name:
Referred by:
Education
High School:
*
Address:
*
From:
*
To:
*
Did you graduate?
*
Yes
No
Diploma:
*
College:
College Address:
From:
To:
Did you graduate?
Yes
No
Degree:
Other:
Technical Colleges, Trade School, etc
Address:
From:
To:
Did you graduate?
Yes
No
Degree:
General
Special Skills:
*
Do you have a valid driver’s license?
*
Yes
No
Which State?
*
Driver’s License/ CDL No.
*
References
Please list three professional references, not related to you, whom you have known for at least 1 year.
Reference 1:
Full Name:
Relationship:
Company:
Phone
Address
Reference 2:
Full Name:
Relationship:
Company:
Phone:
Address:
Reference 3:
Full Name:
Relationship:
Company:
Phone:
Address:
Previous Employment
Company 1:
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:
Ending Salary:
Responsibilities:
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a reference?
Yes
No
Company 2:
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:
Ending Salary:
Responsibilities:
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a reference?
Yes
No
Company 3:
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:
Ending Salary:
Responsibilities:
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a reference?
Yes
No
Military Service
Branch:
From:
To:
Rank at Discharge:
Type of Discharge:
If other than honorable, explain:
Disclaimer and Signature
I agree to the following:
*
Yes
No
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. In consideration of my employment, I agree to conform to the company’s rules and regulations, and I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company’s option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice at any time by the company. I understand that no company representative, other than its president, and then only when in writing and signed by the president, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing.
Consent for Check of Driving Record
Applicants please read carefully and fill out Sections 1 and 2.
Section 1: I agree to the following:
*
Yes
No
I hereby authorize you to release information to Pickett Industries, LLC for the purpose of investigation as required by Section 391.23 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability which may result from furnishing such information.
Section 2: I agree to the following:
*
Yes
No
Fair Credit Reporting Act Disclosure Statement In accordance with the provisions of Section 604(b) (2) (A) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Reform Act of 1996 (Title II, Subtitle D, Chapter 1, of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. These reports are required by Section 382.413, 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations.
Criminal Record Consent
I agree to the following:
*
Yes
No
I hereby give my full consent to Pickett Industries, LLC to obtain any and all of my available criminal records. I understand that this consent is a condition of my employment with Pickett Industries, LLC and that refusal to give consent is reason for immediate dismissal. I also understand that any findings not in compliance with Pickett Industries, LLC policy will be reason for dismissal.
Date of Birth:
*
Race:
Gender:
Signature
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