APPLICATION FOR EMPLOYMENT

PERSONAL

Last Name: First: Middle: Date:
Street Address: Home Telephone:
City: State: Zip: Business Telephone:
Have you ever applied for employment with us? If yes: Month and Year SSN:
Position Desired: Pay Expected:
Are you able to report to work in the assigned position, regardless of shift? Are you able to work overtime if asked?
Are you legally eligible for employment in the United States? Date available to work:
Have you been convicted of a felony in the last seven (7) years? If under 18, can you furnish a work permit?
If yes, please explain:

Why do you want to work for Jackson Tube Service?

NOTE: PROSPECTIVE EMPLOYEES WILL RECEIVE CONSIDERATION WITHOUT DISCRIMINATION BECAUSE OF RACE, CREED, COLOR, AGE, NATIONAL ORIGIN, HANDICAP, OR VETERAN STATUS.

EDUCATIONAL BACKGROUND

School Name & Location Course of study Did you graduate? Degree or Diploma
High School
College
Apprentice, Business, Technical, Vocational, or Military School
Summarize special skills and qualifications acquired from employment or other experiences that may qualify you for work with our company. Please note any licenses, abilities, skills, schooling, or past work experience with regard to the following: Forklift/towmotor operations; measuring devices; mechanical aptitude; ability to use a tape measure (fractions) and/or micrometers.

DRUG TESTING CONSENT AND RELEASE

The undersigned applicant for employment at Jackson Tube Service, Inc. is aware that pre-employment urinalysis is required as a condition for consideration for employment; said urinalysis is conducted to determine the presence of any illegal drug substances.

Since urine collection and analysis is a medical procedure, I irrevocable and voluntarily waive any and all claims to confidentiality, privacy, privilege, or constitutionality regarding the collection, analysis, and test result disclosure, and I agree to hold Jackson Tube Service, Inc. and either:

Piqua, OH: Upper Valley Medical Centers or

Charlotte, North Carolina: Concentra Medical Centers

harmless with respect to the collection and analysis of my urine specimen and the test result disclosure.

________________________________                                                     ____________________

Signature                                                                                                      Date

EMPLOYMENT HISTORY

Company Name: Telephone:
Address: Employed - (State Month and Year)
From To
Name of Supervisor:
Rate/Salary
Starting
Job Title: $ Per
Reason for Leaving
Rate/Salary
Final
May We Contact for Reference? $ Per
Describe Your Work:

 

Company Name: Telephone:
Address: Employed - (State Month and Year)
From To
Name of Supervisor:
Rate/Salary
Starting
Job Title: $ Per
Reason for Leaving:
Rate/Salary
Final
May We Contact for Reference? $ Per
Describe Your Work:

 

Company Name: Telephone:
Address: Employed - (State Month and Year)
From To
Name of Supervisor:
Rate/Salary
Starting
Job Title: $ Per
Reason for Leaving
Rate/Salary
Final
May We Contact for Reference? $ Per
Describe Your Work:

 

Company Name: Telephone:
Address: Employed - (State Month and Year)
From To
Name of Supervisor:
Rate/Salary
Starting
Job Title: $ Per
Reason for Leaving:
Rate/Salary
Final
May We Contact for Reference? $ Per
Describe Your Work:

REFERENCES

Please include professional associates who could be contacted for an employment reference.

Name
Relationship
Occupation
Phone Number

PLEASE READ THE STATEMENT BELOW CAREFULLY: APPLICANT AUTHORIZATION TO RELEASE RECORDS

By pressing the SUBMIT button, I understand that any employment with Jackson Tube Service is voluntarily entered into and, if employed, I may resign at any time for any reason. Similarly, Jackson Tube Service may terminate the employment relationship when it is in its best intere st to do so.

I authorize the investigation of all statements contained in this application, and further authorize Jackson Tube Service to contact my past employees. My present employer be contacted. I certify that all statements and information are true, and acknowledge that any falsification of these facts will disqualify me for employment consideration and/or may be cause for separation from Jackson Tube Service's employment.

I hereby consent and authorize Jackson Tube Service, and any of its agents, to secure information pertaining to my background. I understand that the information supplied by me can be utilized in conducting a background investigation which may include, but not be limited to, criminal history search, driving record history, and verification of any information provided on the application form. I release from liability all persons, companies, and corporations supplying information as a result of this investigation. I further release and indemnify Jackson Tube Service and any of its agents against any liability that might result from conducting such investigations.

In the event I am extended an offer of employment, I understand that I will undergo a physical examination that will be conducted by a company-designated physician.

Driver's License Number:______________________________

State:     ____     Ohio     ____     North Carolina    ____     Other - Specify State ________________________

 

________________________________                                                    ______________________
Applicant's Signature                                                                                    Date

 

FOR JACKSON TUBE SERVICE USE ONLY
Date Interviewed

 
 
 
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