Application

First Name

Last Name

Middle

Address

City/Town

State/Province

Zip/Postal Code

Email

Home Phone

Mobile Phone

Over Twenty-One

Are you over the age of twenty-one? If you are not, hire is subject to verification that you are of minimum legal age

Are you a citizen of the U.S.A

Do you have a valid driver's license?

Yes

No

Do you have a commercial driver's license?

Yes

No

Position(s) being applied for

Hourly Wage Requested

Job Status Applying for

Full Time

Part Time

On what date could you be available for work

List names of friends or relatives working for us

Convictions

Have you been convicted of a crime in the past ten years, excluding misdemeanors and summary offenses. If so list them and if not then please place none in this box.

Elementary School

Name & Address

Last Year Completed

Did You Graduate

High School

Name & Address

Last Year Completed

Did You Graduate

College Education

Name & Address

Last Year Completed

Did You Graduate

Other Education

Name & Address

Last Year Completed

Did You Graduate

Previous Employment 1

Name & Address of Company

Employment Dates

From

To

Job Description

Last Salary

Reason for Leaving

Previous Employment 2

Name & Address of Company

Employment Dates

From

To

Job Description

Last Salary

Reason for Leaving

Previous Employment 3

Name & Address of Company

Employment Dates

From

To

Job Description

Last Salary

Reason for Leaving

Other Skills & Experience

Are there any other experiences, skills, or qualifications which you feel would especially fit you for work with our business

Reference 1

Name

Address

Phone

Reference 2

Name

Address

Phone

Reference 3

Name

Address

Phone

Physical Abilities

Lineman work is very physical. To peform this work you will have to demonstrate several physical abilities essential to Lineman work. These physical abilities are grip strength, upper and lower body muscular strength, muscular endurance, and aerobic capacity. The abilty to lift items of 112 lbs to a hight of 24 inches, lifting items weighing up to 74 lbs ovehead and climbing poles is essential to our work. By checking this box you are attesting that you physically and otherwise able to perform the duties of the job of which you are applying.

I Attest to this information

The facts set forth above in my application for employment are true and complete. I understand that if employed, false statements on this application shall be considered sufficient cause for dismissal. You are hereby authorized to make any investigation of my personal history and financial and credit record through any investigative or credit agencies or bureaus of your choice. I also understand that this application form will be maintained in the active files for one year only unless renewed