Application for Employment
{PRE-EMPLOYMENT QUESTIONNAIRE}    {AN EQUAL OPPORTUNITY EMPLOYER}
PERSONAL INFORMATION
Last Name:   First Name:   Middle Initial:   SSN:
Drivers License Number:   State of Issue:    Email:
Present Address (street, city, state, zip):
Permanent Address (street, city, state, zip):
Are you 18 Years or Older: Yes No        Phone:     Apt. No:
In case of emergency notify (name, address, phone): 
Are you prevented from lawfully becoming employed in this country because of VISA or immigration status?   Yes No
EMPLOYMENT DESIRED
Position:         Date you can start:      Salary Desired:
Are you employed now?Yes No      If so may we inquire of your present employer? Yes No
If no, explain:
What prompted you to apply at Crouch Building Associates?
Are you willing to travel? Yes No
What makes you a team player?
Ever applied to this company before? Yes No   When?
Ever worked for this company before?Yes No   When?
Reason for leaving?
Name of last supervisor at this company:
Who referred you to this company? (employment agency, newspaper ad, etc)
Previous Work Experience: (check all that applies)
Labor      Carp. Mechanical   Carp. Iron Worker    Concrete Finisher   Backhoe Operator
Estimating    Supervisor   Project Manger    CDL License    Cement Mason
Surveyor    Other  (explain: )
 
List number of years Experience in:     Commercial Construction
Supervisor of 3 or more workers:        Managing/Supervising Sub-Contractors:
EDUCATION
Grade School: Name   No. of Years   Graduate? Yes No
High School: Name   No. of Years   Graduate? Yes No
College: Name   No. of Years   Graduate? Yes No
Trade, Business, or Correspondence School: Name   No. of Years           Graduate? Yes No
GENERAL
Subjects of special study or research work:
Special Training:
Special Skills:
List of Equipment that you can operate proficiently:
Forklift Training Card:     CPL  CLASS    First Aid    CPR  (check if applicable)
FORMER EMPLOYERS (list below last three employers, starting with the last one first)
Name and Address of Present or Last Employer:
Starting date (Month/Year):   Leaving Date (Month/Year):
Weekly Starting Salary:          Weekly Final Salary:
Job Title:       May We Contact Your Supervisor: Yes No
Name and Title of Supervisor:
Description of Work:     Reason for Leaving:
 
Name and Address of Present or Last Employer:
Starting date (Month/Year):   Leaving Date (Month/Year):
Weekly Starting Salary:          Weekly Final Salary:
Job Title:       May We Contact Your Supervisor: Yes No
Name and Title of Supervisor:
Description of Work:     Reason for Leaving:
 
Name and Address of Present or Last Employer:
Starting date (Month/Year):   Leaving Date (Month/Year):
Weekly Starting Salary:          Weekly Final Salary:
Job Title:       May We Contact Your Supervisor: Yes No
Name and Title of Supervisor:
Description of Work:     Reason for Leaving:
References (give 3 names of people not related to you whom you have worked with for at least a year)
Name:     Address:   Business:  
Years Acquainted:
 
Name:     Address:   Business:  
Years Acquainted:
 
Name:     Address:   Business:  
Years Acquainted:
Service Record
Branch of Service:   Discharge Date Rank:
Present Membership in National Guard or Reserves: Yes No   Date Obligation Ends:
Special Questions
Height:      Are you a US Citizen: Yes No
Are you able to perform each of the following job functions with or without accommodation:
Job Function 1: Lift and Carry 75 lbs for 100 Feet:  Yes No
If you can perform this function with an accommodation, explain how you would perform the tasks, and with what accommodation:
Job Function 2: Climb Ladder and Work at 30 FT. Above the Ground: Yes No
If you can perform this function with an accommodation, explain how you would perform the tasks, and with what accommodation:
Were You Ever Seriously Injured: Yes No
Give Details:
Are you bilingual?  Yes No        If yes, language:
Proficiency: Speak Fluently?   Yes No          Write Fluently? Yes No  
 
Will you abide by the safety rules of this company? Yes No
 
I understand and agree that I may be required to take a physical examination, drug test, and/or a lie detector test 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 condition with the use of such test(s): Yes No
 
I have been advised that lie detector tests, as a condition of hiring or continued employment, are prohibited by law. 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: Yes No
 
SUPPLEMENTAL INFORMATION - THIS INFORMATION IS MAINTAINED CONFIDENTIALLY
Do you have any misdemeanor or felony convictions?  Yes No
A "yes" response does NOT disqualify you from employment; however, it does require a complete explanation including dates, nature of offense and disposition.
Explain Fully:
 
Do you have any convictions of traffic violations or accidents, including DUI where the fine was more
than $100 over the last three years?  Yes No
A "yes" response does NOT disqualify you from employment; however, it does require a complete explanation including dates, nature of offense and disposition.
Explain Fully:
 
have you ever been denied a license, permit or privilege to operate a motor vehicle or had a license, permit or privilege revoked or suspended? Yes No
A "yes" response does NOT disqualify you from employment; however, it does require a complete explanation including dates, nature of offense and disposition.
Explain Fully:
 
Are you now being investigated for any alleged misconduct or other alleged grounds for discipline by any licensing, certification, or other regulatory body or by your current or any previous employer? If you answer "Yes" you must provide the name, address, and telephone number of the employer or licensing body and a statement of the accusations against you?  Yes No
Explain Fully:
 
I understand that should I fail to list all convictions, my application will not receive further consideration and I will not be considered for employment. I further understand that if I obtain employment with Crouch Building Associates and information is received regarding a conviction, which should have been listed on this application, I will be subject to disqualification and/or dismissal from employment. Yes No
 
Have you ever been dismissed (fired) from any job, or resigned at the request of your employer?          Yes No    If you answer "YES" you must provide the date of termination of employment, the name, address and telephone number of the employer(s) and a statement of the alleged reasons for the termination. A "YES" answer is not disqualifying and will be considered individually, but should be explained fully.
AUTHORIZATION
I certify that all the information submitted by me on this application is true and complete, and I understand that if any false information, omissions, or misrepresentations are discovered, my application my be rejected and, if I am employed, my employment may be terminated at any time. In consideration of my employment, I agree to conform to the company's rules and regulations, and I agree that my employment and compensation can be germinated, with or without cause, and with or without notice, at any time, at either my or the company's option. I also understand and agree that the terms and condition of my employment may be changed, with or without cause and with or without notice, at any time by the company. I understand that no company representative, other than its president, and then only when in writing and signed by the president, has any authority to enter into any agreement for employment for any specific period of time, or to make an agreement contrary to the foregoing.
Electronic Name/Signature:    Date: