Fields marked with a * are required. Date of Application: Basic Information Name: * Address: * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming How long at *this address? Email: * Telephone: * More Information If you are under 18, can you provide a work permit? Yes No Have you ever been employed here before? Yes No Are you legally eligible for employment in this country? Yes No Date available to start? Position Applied for: Desired Salary: Employment desired: Full-Time Part-Time Full or Part Time How many hours per week? Day/Hours Available: No Preference Mon Tue Wed Thu Fri Sat Sun Have you been convicted of a felony? Yes No If yes, please explain: Have you been in the armed forces? Yes No Are you now a member of the National Guard? Yes No Specialty Date Entered: Discharge Date Do you have a drivers license? Yes No What is your means of transportation to work? Driver's license number State of issue Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Type: Operator Commercial (CDL) Expiration Date: 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? Employment History * Start with most recent on top. Employer #1 From To Employer Telephone Job Title Employer Address Immediate Supervisor and Title Summarize the nature of work performed and job responsibilities Reason for Leaving Hourly Rate/Salary Start $ per Final $ per Employer #2 From To Employer Telephone Job Title Employer Address Immediate Supervisor and Title Summarize the nature of work performed and job responsibilities Reason for Leaving Hourly Rate/Salary Start $ per Final $ per Employer #3 From To Employer Telephone Job Title Employer Address Immediate Supervisor and Title Summarize the nature of work performed and job responsibilities Reason for Leaving Hourly Rate/Salary Start $ per Final $ per May we contact your present employer? Yes No Educational Background Name and Location Years Completed Did you graduate? Course of Study High School College Other Other References Name Telephone Years Known Additional Comments * Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you're applying I certify that all of the information on this application is accurate and complete to the best of my knowledge and understand that misleading or false statements will constitute sufficient cause for refusal of hire or termination of my employment. I understand that neither the acceptance of this application nor the subsequent entry into any type of employment relationship with Eau Claire Roofing Co. Inc. creates an actual or implied contract of employment. I understand that, if I accept employment with Eau Claire Roofing Co. Inc., it will be on an at-will basis. This means that either Eau Claire Roofing Co. Inc. or I have the right to terminate the employment relationship at any time, for any reason, with or without cause. I agree to submit to drug and alcohol testing, if requested by Eau Claire Roofing Co. Inc. I release Eau Claire Roofing Co. Inc. and its employees, plus other persons or companies, from any and all liability arising out of or related in any way to such testing. I authorize Eau Claire Roofing Co. Inc. to investigate information concerning my education, employment experiences and all other aspects of my background relevant to my propose employment. I release Eau Claire Roofing Co. Inc. and its employees from all liability arising from such investigation. Did you complete this application yourself? Yes No If no, who did? Signature of Applicant * Date Eau Claire Roofing Co. Inc. is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age, or disability. We assure you that your opportunity for employment with Eau Claire Roofing Co. Inc. depends solely on your qualifications.