Paul Jackson & Son/Application

Application for employment - Applicant Information

***PLEASE NOTE THAT ENTIRE APPLICATION MUST BE FILLED OUT FOR CONSIDERATION - IF “NO” ANSWER APPLIES, PUT N/A IN BLANK. LEAVE NO BLANK SPACES. ***

Are you a U.S. Citizen or approved to work in the US?*

Are you over 18?*

Have you been convicted of a felony?*

Have you been released from prison in the last 7 years?*

If Yes, State Details and charges

In case of emergency, please notify

Education Background

High School Name

Location (City, State)

Grade Completed

Year Graduated

College Name

Location (City, State)

Degree Earned

College Major:

Year Graduated

Trade School

Location (City, State)

Certification Earned

Field of Trade:

Year Graduated

PJ&S Employment Background

Most Recent Employer

List Most Recent Employer*

Date of Employment*

Starting Salary*

Job Title*

Supervisor*

Salary Leaving*

Phone Number*

Reason for Leaving*

Does PJ&S Have Permission To Call & Verifyy Information*

If No, Give Reason

Next Most Recent Employer

List Next Most Recent Employer

Date of Employment

Starting Salary

Job Title

Supervisor

Salary Leaving

Phone Number

Reason for Leaving

Does PJ&S Have Permission To Call & Verifyy Information

If No, Give Reason

Next Most Recent Employer

List Next Most Recent Employer

Date of Employment

Starting Salary

Job Title

Supervisor

Salary Leaving

Phone Number

Reason for Leaving

Does PJ&S Have Permission To Call & Verifyy Information

If No, Give Reason

Have you ever been employed by Paul Jackson & Son, INC.?*

If so, who was your supervisor?

Reason for leaving:

Do you have any family members working for Paul Jackson & Son, INC.?*

If yes, who?

Personal References

List three personal references (other than relatives or employers)

Job Specifics

1st Position Applying For:

Salary Desired:

Location Preferred:

Date Available:

2nd Position Applying For:

Salary Desired:

Location Preferred:

Date Available:

Type of employment desired: (SELECT ONE)*

If hired - When can you start?*

Do you have a valid driver's license?*

Do you have reliable personal transportation?*

If not, how would you get to work?

Equipment Experience

Truck

Backhoe

Forklift

Crane

Other:

Can you read a tape measure?*

Can you read blue prints?*

If Yes

Can you effectively operate the following:

Circular Saw?*

Rotary Hammer?*

Drill?*

Tamp?*

Shovel?*

Table Saw?*

Pick?*

Maul?*

Nail Gun?*

Screw Gun?*

Router?*

List any other tools you can effectively operate:

List any other information or skills you feel are pertinent:

Medical History

Health Questionnaire

The type of work you are applying for could be physical in nature. PJ&S does not want to put you in a situation that could harm you or aggravate your ailment. Do you have or have you ever had any of the following?

Please check EACH of the following items YES or NO. Please list details to any item answered YES on the space supplied below. You must answer ALL QUESTIONS!

Epilepsy*

Diabetes*

Cardiac (Heart)*

Knee Problems*

Any Loss of Vision*

Any Amputation*

Cerebral Palsy*

Multiple Sclerosis*

Parkinson's Disease*

Vascular Disorders*

Foot Problems*

Hand Problems*

Back Problems*

Psychiatric*

Psychological*

Hemophilia*

Blood Disease*

Osteomyelitis*

Stiff Joints*

Hypoglycemia*

Muscular Dystrophy*

Shoulder Problems*

Herniated Disk*

Back Surgery*

Allergies*

Breathing Disorders*

Leg Problems*

Arm Problems*

Neck Problems*

Please list ANY disorder or ailment you have or have had in the past that is not listed above:

Please list ANY task that a doctor has stated you shouldn't be doing or would restrict your ability to do any construction task assigned to you:

Explain any answer to any item above marked YES:

Application for employment - Agreement

READ THE FOLLOWING STATEMENT AND SIGN BELOW

I have not been and am not now a member of any organization which advocates the forceful overthrow of the U.S. Government.

I also state that I am a legal citizen of the United States of America.

If not a legal citizen, I hereby state that I am in the United States of America legally and if hired will supply PJ&S copies of papers showing that I am legally in the United States of America. I also agree that, if hired, I will notify PJ&S immediately when this legal status changes.

I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision.

I hereby authorize Employers, Schools, Doctors, Hospitals or Persons to give any information regarding me in responding to inquiries in connection with my application. Upon my written request, within a reasonable time, additional disclosure concerning the nature and scope of the information requested will be provided.

I understand that misrepresentation or omission of the facts called for herein will be sufficient cause for cancellation of the application and/or for termination from the Company's service if I have been employed. I also understand that employment is subject to a satisfactory physical examination, including taking a drug test if requested, by a physician if PJ&S deems necessary.

I hereby acknowledge that any action, damage and liability caused by the misrepresentation or omission of any requested information on this application will be the applicant's responsibility. PJ&S will be reimbursed by the applicant for any cost due to misrepresentation of the facts by the applicant.

SIGNATURE OF APPLICANT*

TODAY'S DATE*

***PLEASE NOTE THAT ENTIRE APPLICATION MUST BE FILLED OUT FOR CONSIDERATION - IF “NO” ANSWER APPLIES, PUT N/A IN BLANK. LEAVE NO BLANK SPACES. ***