APPLICATION FOR EMPLOYMENT

Equal Opportunity Employer

Date:

PERSONAL INFORMATION

Name Last:    First:    Middle:

Phone Number:   Alternate Phone:

Drivers License Class:

Address Street:

City:    State:     Zip:

Are You 18 Years or Older? Yes  No   Email:

Special Questions

Are you legally authorized to work in the U.S.? Yes  No
Proof of identity and eligibility will be required upon hire.

What Foreign Languages do you speak fluently?

Read?

Write?

Have you been convicted of a felony or misdemeanor within the last 5 years?
** Yes  No

Describe:

**You will not be denied employment solely because of a conviction record, unless the offense is related to the job for which you have applied.

I understand and agree that I may be required to take one or more: Physical examination; Drug screen; Physical Base Line as a condition of hiring or continued employment. I agree to consent to take such test(s) at such time as designated by the Company and to release the Company, its directors, officers, agents or employees from any claim arising in connection with the use of such tests. Yes  No

EMPLOYMENT DESIRED

Position:  (See Job Descriptions)

Date You can start:  Salary desired:

Are You Employed Now? Yes  No:

If So May We Inquire of Your Present Employer? Yes  No

Ever Worked for Smoky Hill Const. Before? Yes  No

Where?  When?

EDUCATION

HIGH SCHOOL

Location
of School
Years
Attended
Year
Graduated
Favorite Subjects

COLLEGE

Location
of School
Years
Attended
Year
Graduated
Major Studies

TRADE SCHOOL OR OTHER EDUCATION

Location
of School
Years
Attended
Year
Graduated
Major Studies

*The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age.

GENERAL

Subjects of Special Study or Research Work

U.S. Military or Navel Service

Rank

Present Membership in National Guard or Reserves

FORMER EMPLOYERS

(List Below Last Three Employers, Starting With The Last One First).

Name of Employer

Address of Employer

Phone Number:

Salary    Job Title 

Job Duties

Reason for Leaving

From    To 

Name of Employer

Address of Employer

Phone Number:

Salary    Job Title 

Job Duties

Reason for Leaving

From    To 

Name of Employer

Address of Employer

Phone Number:

Salary    Job Title 

Job Duties

Reason for Leaving

From    To 

REFERENCES:

Give the Names of Three Persons not Related to You, Whom You Have Known at Least One Year.

Name    Address 

Phone:

Business    Years Acquainted 

Name    Address 

Phone:

Business    Years Acquainted 

Name    Address 

Phone:

Business    Years Acquainted 

Can you Perform the Essential Functions of Your Job, With or Without a Reasonable Accommodation?  Yes     No  (See Basic work requirements)

Please Describe 

Voluntary EEO Self-Identification Form

The Company is an equal opportunity employer and does not discriminate against applicants or employees on the basis of race, color, religion, sex national origin, age, disability, veteran status, citizenship or any other characteristic protected by federal, state or local laws. The purpose of this form is to assist the Company in complying with required government record keeping and reporting requirements as well as affirmative action obligations, if applicable. This information is not part of your employment application and will not be considered in the employment/selection process. The information requested is voluntary and will be kept confidential. If you choose not to provide this information, you will not be subject to any adverse treatment. If you choose to provide the information, please complete the following:

Sex:   Male  Female

RACE/Ethnicity
Are you Hispanic or Latino? (A person of Cuba, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin regardless of race.)

Yes   No

If you answered “No” to “Are you Hispanic or Latino?” please indicate what race/ethnicity you believe yourself to be:

 American Indian or Alaskan Native (Not Hispanic or Latino)- A person having origins in any of the original peoples of North or South American (including Central America) and who maintain tribal affiliation or community attachment.

 Asian (Not Hispanic or Latino)- A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, china, India, Japan, Korea, Malaysia, Pakistan, the Philippines Islands, Thailand, and Vietnam.

 Black or African American (Not Hispanic or Latino- A person having origins in any of the black racial groups of Africa.

 Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino- A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

 White (Not Hispanic or Latino- A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

 Two of More Races (Not Hispanic or Latino- All persons who identify with more than one of the above five races.

Referral Source:
Newspaper       Kansas Works
Internet Ad       Relative
Friend       Other:

Voluntary Veterans and Disability Self- Identification Form

The Company is an equal opportunity employer and does not discriminate against applicants or employees on the basis of race, color, religion, sex national origin, age, disability, veteran status, citizenship or any other characteristic protected by federal, state or local laws. The purpose of this form is to assist the Company in complying with required government record keeping and reporting requirements as well as affirmative action obligations, if applicable. This information is not part of your employment application and will not be considered in the employment/selection process. The information requested is voluntary and will be kept confidential. If you choose not to provide this information, you will not be subject to any adverse treatment. If you choose to provide the information, please complete the following:

Are you and individual with a disability? (You may be an individual with a disability if you have a physical or mental impairment, which substantially limits you in one or more major life activity, or have a record of having such impairment, or are regarded as having such impairment.)

Yes   No

Veteran Status

Special Disabled Veteran

  1. A veteran who is entitled to compensation under laws administered by the Department of Veteran Affairs for a disability (a) rated at 30% or more, or (b) rated at 10% or 20% if it has been determined that the individual has a serious employment disability; or
  2. A veteran who was discharged or release from active duty because of a service-connected disability.

Vietnam Era Veteran

  1. Served in the military, ground, naval or air service of the U.S. on active duty for a period of more than 180 days, and was discharged or released there from with other that a dishonorable discharge, if any part of such active duty occurred: (a) in the Republic of Vietnam between 02/28/1961 and 05/07/1975; or (b) between 08/05/1964 and 05/07/1975, in all other cases; or
  2. Was discharged or released from active duty for a service connected disability if any part of such active duty was performed: (a) in the Republic of Vietnam between 02/28/1961 and 05/07/1975; or (b) between 08/05/1964 and 05/07/1975, in all other cases.

Recently Separated Veteran

  1. Any veteran who served on active duty during the three year period on the date of such veteran’s discharge or release from active duty.

Other Protected Veteran

  1. A veteran who served on in the military, ground, naval or air service of the U.S. on active duty during a was or in a campaign or expedition for which a campaign badge has been authorized.

Armed Forces Service Medal Veteran

  1. 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 services medal was awarded pursuant to Executive Order 12985.

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you.

If hired, I understand that my employment is at-will and can be terminated at any time, with or without notice, for any reason at the option of the company or me. Should the company hire me, I agree to observe all the company’s policies, practices and procedures currently in existence and new or revised ones, which may be issued in the future.

Date

Signature

Submit this application only if all answers are completely accurate. Refer to the following information:

A. Basic work requirements.

B. Job Descriptions.

Potential candidate for employment must authorize investigative reports