Application

Position applying for:(Required)

Name(Required)

First Middle Last

Email(Required)

Phone(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Do you have the legal right to work in the United States?(Required)

Yes

Are you over the age of 21?(Required)

Yes

Can you provide proof of age?(Required)

Yes

Have you worked for this company before?(Required)

Yes

From Date(Required)

To Date(Required)

Rate of Pay:(Required)

Position:(Required)

Reason for leaving:(Required)

Are you now employed?(Required)

If not, how long since leaving last employment?(Required)

Who referred you?(Required)

Rate of pay expected?(Required)

Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the attached job description)?

If yes, explain if you wish

Employment History

(Note: List employers in reverse order starting with the most recent.)

Employer Name

Date From

Date To

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Position Held

Contact Person

Reason for leaving

Salary/Wage

Employer Name

Date From

Date To

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Person

Position Held

Salary/Wage

Reason for leaving

Add more employers if needed

We may contact the employers listed above unless you indicate those you do not want us to contact.

DO NOT CONTACT

Employer

Reason

Military

We may contact the employers listed above unless you indicate those you do not want us to contact.

Did you serve in the U.S. Armed Forces?(Required)

Yes

Which branch(Required)

References Excluding Former Employers or Relatives

Name

Address

Position/Business Connection

Phone Number

Years Known

Education

Highest Grade Completed(Required)

Last School Attended:

Name(Required)

City(Required)

Experience & Qualifications-Other

Show any trucking, transportation or other experience that may help in your work for this company?

List courses and training that may help you in your work for this company.

List special equipment or technical materials you can work with.

In accordance with the American Disabilities Act 942 USC 12101, Title 1, sec. 102 (d)(2)(B) and Act 942 USC 12101, Title 1 sec. 102(d)(3)(B)

Please answer the following questions:

Are you able to perform the following functions repetitively during an entire normal (8) hour day without restriction or pain?

Lift up to 50 lbs (Objects)

Yes

If not, how may lbs?(Required)

Bending

Yes

Drive Long Haul trucks

Yes

Twisting

Yes

Loading/Unloading trucks

Yes

Squatting

Yes

Sitting

Yes

In accordance with the American Disabilities Act 942 USC 12101, Title 1, Sec. 102 (d)(3)(B) will you please answer the following questions:

Please list all doctors or medical care providers you have seen in the last (5) years. If “None” write the word “None”

Please list all industrial (Workman’s Comp.) accidents in which you have been involved in the last (5) years. If “None” write the word “None”

BEING DULY SWORN, THE UNDERSIGNED RELEASES TO MICKELSEN CONSTRUCTION, INC. ALL RELATED MEDICAL INFORMATION AND STATES THAT ALL THE ABOVE ANSWERS ARE TRUE AND CORRECT.

Applicant Signature(Required)

Date(Required)

Employment History

Military

Education

Last School Attended:

Experience & Qualifications-Other

In accordance with the American Disabilities Act 942 USC 12101, Title 1, sec. 102 (d)(2)(B) and Act 942 USC 12101, Title 1 sec. 102(d)(3)(B)

In accordance with the American Disabilities Act 942 USC 12101, Title 1, Sec. 102 (d)(3)(B) will you please answer the following questions:

BEING DULY SWORN, THE UNDERSIGNED RELEASES TO MICKELSEN CONSTRUCTION, INC. ALL RELATED MEDICAL INFORMATION AND STATES THAT ALL THE ABOVE ANSWERS ARE TRUE AND CORRECT.

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