Employment Application "*" indicates required fields Name* First Middle Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneEmail Are you a citizen of the United States?* Yes No Are you authorized to work in the United States?* Yes No Are you 18 years of age or older?* Yes No Have you ever bee convicted of a felony?* Yes No Please Explain* Employment DesiredPosition Applied for:* Date Available to Work* MM slash DD slash YYYY Salary Desired:*Have you ever worked for this company before?* Yes No If yes, when?* Supervisor's Name Referred by:* EducationHigh School Attended* Address* Did you graduate?* Yes No From:* MM slash DD slash YYYY To* MM slash DD slash YYYY College Attended Address Did you graduate? Yes No From: MM slash DD slash YYYY To* MM slash DD slash YYYY Other Address From: MM slash DD slash YYYY To* MM slash DD slash YYYY Special Skills Add RemoveUse the "+" to add each item to the list.Do you have a valid Driver's License?* Yes No Which State?* Driver’s License/ CDL No:* ReferencesPlease list three professional references, not related to you, whom you have known for at least 1 year.Full Name* Reference #1Relationship* Company* Phone*Address* Full Name* Reference #2Relationship* Company* Phone*Address* Full Name* Reference #3Relationship* Company* Phone*Address* Previous EmploymentPlease list the last three companies with whom you have been employed.Company #1 PhoneSupervisor Address Job Title Starting SalaryEnding SalaryResponsibilities Reason for Leaving Date worked FROM MM slash DD slash YYYY Date worked TO MM slash DD slash YYYY May we contact your previous supervisor for a reference? Yes No Company #2 PhoneSupervisor Address Job Title Starting SalaryEnding SalaryResponsibilities Reason for Leaving Date worked FROM MM slash DD slash YYYY Date worked TO MM slash DD slash YYYY May we contact your previous supervisor for a reference? Yes No Company #3 PhoneSupervisor Address Job Title Starting SalaryEnding SalaryResponsibilities Reason for Leaving Date worked FROM MM slash DD slash YYYY Date worked TO MM slash DD slash YYYY May we contact your previous supervisor for a reference? Yes No Were you in the military? Yes No Military ServiceBranch Date worked FROM MM slash DD slash YYYY Date worked TO MM slash DD slash YYYY Rank at Discharge Type of Discharge If other than honorable, please explain: Disclaimer and SignatureConsent* I agree to the following.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* I agree to the following.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.Consent* I agree to the following.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.Consent for Criminal Record* I agree to the following.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* MM slash DD slash YYYY Race Gender Signature*
