EMPLOYMENT APPLICATION

Personal Information

Your Name

Your Email

Best Phone Number

Address: Number, Street, City State, Zip

Last Four Digits of SS#

Are You Over 18?
YesNo

Do you know anyone who works for us currently?
YesNo

If yes, what are their names?

Are you legally authorized to work in the US?
Note: Verification of eligibility to work in the US is required at the time of hire.
YesNo

Answering "yes" to either of the questions below will not necessarily bar you from employment

Have you ever been convicted of a crime?
YesNo

Are you currently on parole or probation from a criminal conviction?
YesNo

Employment Desired

Type of position desired?

Are you interested in full time, part time, or temporary work?
Full TimePart TimeTemporary

Which shifts are you available for?
1st Shift2nd Shift3rd Shift

Are you willing and able to work overtime if you are hired?
YesNo

Date that you can start:

Desired salary:

Are you currently employed?
YesNo

If so, may we contact your employer?
YesNo

Have you ever worked for Bailey Asphalt? If so, when?

Please list any skills, qualifications, business machines, etc.

List any certificates earned or in progress, and/or any individual training programs not in your formal education.

Education

Please list your highest level of education.
ElementaryHigh SchoolCollegeGraduate SchoolTechnical / Other

When did you graduate?

Employment Experience

Start with your most recent or present employer, and provide all employers leaving no gaps in your work history for the last 3 places of employment. Include any military service that may be responsible for a gap.

Employer #1

Name:

Address:

Phone:

Supervisor:

Please list your start and end dates:

Please list your ending rate of pay:

What was your job title?:

What was your reason for leaving?

Employer #2

Name:

Address:

Phone:

Supervisor:

Please list your start and end dates:

Please list your ending rate of pay:

What was your job title?:

What was your reason for leaving?

Employer #3

Name:

Address:

Phone:

Supervisor:

Please list your start and end dates:

Please list your ending rate of pay:

What was your job title?:

What was your reason for leaving?

I certify that the information contained in this application is correct to the best of my knowledge and understand that deliberate falsification of this information is grounds for dismissal in accordance with this company's policy. I authorize 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. (I agree to undergo a character investigation and, if requested by the employer or law officials, an honesty verification test. I understand that no representative of the company has the authority to enter into any agreement for employment for any specified period of time, nor am I obligated to work for the company for any specified period of time.

Submission of this form is your signature.