Please complete the following information:

    Job Location
    Position Applied For
    Sometimes a job may require that we work at night, to avoid
    heavy traffic, thus creating a safer work environment for our
    employees.
    Can you work nights?

    YesNo

    Can you work weekends?
    YesNo

    Are you willing to work overtime?
    YesNo

    Are you willing to travel out of town with overnight stays?
    YesNo

    How did you learn about us?
    AdvertisementEmployment agencyFriendRelativeWalk InOther

    Employment Desired
    Full TimePart TimeFull or Part Time

    When are you available to start work?

    Do you speak or write any foreign languages?
    YesNo

    If so, what language(s)?

    Are you a citizen of the United States?
    YesNo

    If no, are you authorized to work in the U.S.?
    YesNo

    Have you ever worked for this company?
    YesNo

    If so, when?

    Have you ever been convicted of a felony?
    YesNo

    If yes, explain.

    Have you ever had an adjudication withheld, or nolo contendere?
    YesNo

    If yes, explain.

    EDUCATION

    High school

    Address

    From

    To

    Did you graduate?
    YesNo

    Diploma?
    YesNoGED

    College

    Address

    Attended college from

    Attended college until

    Did you graduate?
    YesNo

    Degree

    Business or Trade School

    Address

    Business or trade school attended from

    Business or trade school attended until

    Did you graduate?
    YesNo

    Degree

    Do you have a driver's license?
    YesNo

    Do you have reliable transportation to work?
    YesNo

    Driver's license number

    State of Issue

    Expiration Date

    Type
    OperatorCommercial (CDL)Chauffeur

    Have you had any accidents during the past three years?
    YesNo

    How many?

    Have you had any moving violations during the past three years?
    YesNo

    How many?

    REFERENCES

    Please list three professional references.

    #1 Full Name

    Relationship

    Company

    Phone

    Address

    #2 Full Name

    Relationship

    Company

    Phone

    Address

    #3 Full Name

    Relationship

    Company

    Phone

    Address

    An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying.

    PREVIOUS EMPLOYMENT

    Company #1

    Phone

    Address

    Job Title

    Supervisor

    Starting Pay Rate

    Ending Pay Rate

    From

    To

    Reason for Leaving

    May we contact your previous supervisor for a reference?
    YesNo

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

    Company #2

    Phone

    Address

    Job Title

    Supervisor

    Starting Pay Rate

    Ending Pay Rate

    From

    To

    Reason for Leaving

    May we contact your previous supervisor for a reference?
    YesNo

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

    Company #3

    Phone

    Address

    Job Title

    Supervisor

    Starting Pay Rate

    Ending Pay Rate

    From

    To

    Reason for Leaving

    May we contact your previous supervisor for a reference?
    YesNo

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

    PLEASE READ CAREFULLY

    APPLICATION FORM WAIVER

    In exchange for the consideration of my job application by C.W. Roberts Contracting, Inc. (hereinafter called “the Company”), I agree that:
    Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any
    other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may
    exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to
    remain an employee of C.W. Roberts Contracting, Inc., or otherwise to change in any respect the employment-at- will relationship between it and the
    undersigned, and that relationship cannot be altered except by a written instrument signed by the President/General Manager of the Company. Both
    the undersigned and C.W. Roberts Contracting, Inc. may end the employment relationship at any time, without specified notice or reason. If
    employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include a
    reduction in benefits.

    I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is
    cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless
    otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contract.
    I also understand that (1) the Company has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment;
    (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing
    of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical
    examinations.

    I certify that I have received a written notification that the Company may obtain a consumer report or reports on me. I authorize this Company to
    obtain such a report or reports for use in connection with my application for employment and for other employment-related reasons. If hired, this
    authorization shall remain on file and serve as ongoing authorization for procurement of employment-related consumer reports at any time during my
    employment. I understand that the term “consumer report” includes, but is not limited to, credit checks, criminal background checks, Department of
    Motor Vehicle reports, and investigative consumer reports. I authorize the Company to conduct electronic inquiry related to my background,
    including review of all social networking sites and to make adverse decisions as a result of such inquiries. I further understand that the term
    “investigative consumer report” means a report in which information on my character, general reputation, personal characteristics, or mode of living
    is obtained through personal interviews with my neighbors, friends, or associates, or with others with whom I am acquainted or who may have
    knowledge concerning any such items of information.

    I further understand that my employment with the Company shall be probationary for a period of (90) days, and further that at any time during the
    probationary period or thereafter, my employment relation with the Company is terminable at will for any reason by either party.
    This Company provides equal employment opportunities to all employees and applicants without regard to race, color, religion, sex,
    sexual orientation, national origin, citizenship, age, pregnancy, disability, or any other protected status. We assure of my job application by C.W. Roberts Contracting, Inc. (hereinafter called “the Company”), I agree that:

    Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any
    other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may
    exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to
    remain an employee of C.W. Roberts Contracting, Inc., or otherwise to change in any respect the employment-at- will relationship between it and the
    undersigned, and that relationship cannot be altered except by a written instrument signed by the President/General Manager of the Company. Both
    the undersigned and C.W. Roberts Contracting, Inc. may end the employment relationship at any time, without specified notice or reason. If
    employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include a
    reduction in benefits.

    Acknowledgment and Agreement:

    EEO SURVEY

    We consider applicants for all positions without regard to race, color, sex, national origin, religion, age, marital status, genetic information status, pregnancy, disability, veteran status, sexual orientation, gender identification, transgender, or any other legally protected class. The information requested on this form is collected by the company to comply with Affirmative Action/Equal Employment Opportunity and other federal laws and regulations. This information is considered confidential and will not be a part of your official application for employment.

    Position title for which you are applying:

    Gender:
    MaleFemale

    Date of Birth:

    Race:
    Hispanic or LatinoWhite (Not Hispanic or Latino)Black or African AmericanNative Hawaiian or Other Pacific IslanderAmerican Indian or Alaska NativeAsianTwo or More Races

    You are invited to identify yourself as a disabled veteran, veteran of the Vietnam Era, or disabled individual. This information is voluntary and will be kept confidential. Refusal to provide it will not subject you to any adverse treatment. The information will be used for affirmative action purposes. It is not used or considered in the selection process and is filed separately from the application.

    The Vietnam Era is defined by Federal Regulations as August 5, 1964 to May 7, 1975.

    Veteran Status: Which applies to you?

    Disabled Veteran: A Veteran entitled to compensation for disability rated at 30% or more, or a person who is discharged or released from active duty because of a service connected disability.Recently Separated Veteran: A Veteran who served on active duty in the U.S. military, ground, naval or air service during the three-year period beginning on the date of such veteran’s discharge or release from active duty.Active Duty Wartime or Campaign Badge Veteran: A Veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized by the Department of Defense.Armed Forces Service Medal Veteran: A Veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.I am a protected veteran, but I choose not to self identify the classifications to which I belong.I am not a protected veteran.

    To qualify as a Disabled Individual, you must:
    1. Have a physical or mental impairment which substantially limits one or more life activities (including employment);
    2. Have a record of such impairment; or
    3. Be regarded as having such impairment.

    Do you qualify as such an individual?

    YesNo

    This information is for compliance reporting only.
    It will be removed from your application prior to review.
    It is not considered in the employment process.