An Equal Opportunity Employer

We do not discriminate on the basis of race, color, religion, national origin, sex, age, or disability. It is our intention that all qualified applicants are given equal opportunity and that selection decisions are based on job-related factors.

Name*

First Middle Last Maiden

Present address*

Street Address City State Zip Code

How long?*

Telephone*

Email*

If under 18, please list age

Position applying for*

Salary desired*

Days / hours available to work*

Employment desired*

Full-time Only

Part-time Only

Full or Part Time

Have you worked for Black Roofing & Waterproofing before?*

Yes

No

If so, when did you leave?

Are you able and willing to travel and stay overnight for work?*

Yes

No

How many hours can you work weekly?*

Can you work nights?*

When are you available to work?*

Education:

High School

Name and Address of School

Number of Years Completed

Diploma / Degree / Certificate

College

Name and Address of School

Number of Years Completed

Diploma / Degree / Certificate

Business or Trade School

Name and Address of School

Number of Years Completed

Diploma / Degree / Certificate

Professional School

Name and Address of School

Number of Years Completed

Diploma / Degree / Certificate

Driving Information:

Do you have a driver’s license?*

Yes

No

What is your means of transportation to work?*

Driver’s License Number*

State of Issue*

Expiration Date*

Type*

Have you had any accidents in the past three years?*

Yes

No

How many?*

Have you had any moving violations in the past three years?*

Yes

No

How many?*

Military:

Have you ever been in the armed forces?*

Yes

No

Are you now a member of the national guard?*

Yes

No

Specialty

Date Entered

Date Discharged

Work Experience:

Please list your work experience for the past five years beginning with your most recent job held. If you were self-employed, give your firm name.

Employer 1 (Most Recent)

Name of Employer*

Address*

Telephone*

Name of Last Supervisor*

Your Last Job Title*

Reason for Leaving*

Employed To:*

Employed From:*

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.*

Employer 2

Name of Employer

Address

Telephone

Name of Last Supervisor

Your Last Job Title

Reason for Leaving

Employed From:

Employed To:

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

Employer 3

Name of Employer

Address

Telephone

Name of Last Supervisor

Your Last Job Title

Reason for Leaving

Employed From:

Employed To:

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

May we contact your present employer?*

Yes

No

Additional Info:

Did you complete this application yourself?*

Yes

No

If not, who did?

In case of emergency, whom do we contact?

Emergency Contact Name*

Relationship*

Phone*

Address*

Street Address City State ZIP Code

By signing below, I hereby swear that the information provided above is true to the extent of my knowledge and I understand that false or misleading information will result in my not being offered employment or, if hired, may result in my immediate termination.

Signature*

Date*

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An Equal Opportunity Employer

Education:

Driving Information:

Military:

Work Experience:

Employer 1 (Most Recent)

Employer 2

Employer 3

Additional Info:

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