Employment at McCullough Excavating

"*" indicates required fields

DESIRED EMPLOYMENT

Position Applying For*

Referred by

YOUR CONTACT INFORMATION

Name (Last, First, Middle)*

Date*

MM slash DD slash YYYY

Present Address*

Street Address City State ZIP Code

Email*

Cell Phone Number*

Phone Number*

EMPLOYMENT EXPERIENCE

Start with most recent

Company Name

Date of Hire

MM slash DD slash YYYY

Date of Separation

MM slash DD slash YYYY

Address

Street Address City State ZIP Code

Position

Phone Number

Reason For Leaving

Supervisor's Name

Description of Duties

Ending Wage

Additional Employment?

Yes

Company Name

Date of Hire

MM slash DD slash YYYY

Date of Separation

MM slash DD slash YYYY

Address

Street Address City State ZIP Code

Position

Phone

Reason for Leaving

Supervisor's Name

Description of Duties

Ending Wage

Additional Employment?

Yes

Company Name

Date of Hire

MM slash DD slash YYYY

Date of Separation

MM slash DD slash YYYY

Address

Street Address City State ZIP Code

Position

Phone Number

Reason for Leaving

Supervisor's Name

Description of Duties

Ending Wage

Additional Employment?

Yes

Company Name

Date of Hire

MM slash DD slash YYYY

Date of Separation

MM slash DD slash YYYY

Address

Street Address City State ZIP Code

Position

Phone Number

Description of Duties

Ending Wage

EDUCATION

High School (Name and Location)

Years Completed

GPA

Degree

Graduated?

Yes

Technical or Vocational (Name and Location)

Years Completed

GPA

Degree / Major

Graduated?

Yes

College or University (Name and Location)

Years Completed

GPA

Degree / Major

Graduated?

Yes

College or University - Post Graduate (Name and Location)

Years Completed

GPA

Degree / Major

Graduated?

Yes

INFORMATION

Valid Drivers License

Yes

Reliable Transportation

Yes

Are you willing to work in emergency situations where water and fire damage cleanup will be necessary and required?

Yes

Will you work overtime if required?

Yes

Are you legally authorized to work in the United States?

Yes

Have you ever been terminated, separated involuntarily or suspended from any position?

Yes

Please describe

May we contact your current employer?

Yes

Are you 18 years old or older? (If no, a job permit may be required)

Yes

Have you had any alcohol or illegal drug related driving infractions in the past seven (7) years?

Yes

Have you been convicted of any felonies in the last seven (7) years?

Yes

If yes, please explain (such conviction may be relevant if job related, but does not bar you from employment)

Date Availabel for Work

MM slash DD slash YYYY

Salary Desired

SKILLS, ABILITIES, CERTIFICATIONS, LICENSES OR SPECIALIZED TRAINING

Please list all skills, abilities, certifications, licenses or specialized training

PROFESSIONAL REFERENCES

Name

Place of Employment

Relationship

Phone Number

Years Known

Name

Place of Employment

Relationship

Phone Number

Years Known

Name

Place of Employment

Relationship

Phone Number

Years Known

SIGN AND SUBMIT

APPLICANT CERTIFICATION THAT INFORMATION IS ACCURATE AND COMPLETE: I attest that the information provided on this application (and accompanying resume if applicable) is true and complete. I understand that any false information, misrepresentation, or omission – oral or written – may disqualify me from further consideration for employment and, if hired, may result in discipline or dismissal if discovered at a later date.

APPLICANT’S CONSENT TO VERIFY INFORMATION AND RELEASE: I authorize McCullough Excavating to investigate my employment history and all statements contained in this application, including records of any former employers and other references or sources concerning me. I authorize all references and sources to provide this information to McCullough Excavating and release such references and sources from liability for doing so. I waive my right to any written notice of the release of such records that may be required by state or federal law.

APPLICANT’S CONSENT TO INVESTIGATIVE CONSUMER REPORT: I understand that due to the nature of the jobs at “McCullough Excavating an investigative consumer report may be made whereby information is obtained through interviews with various third parties. These inquires may include information as to criminal, credit, driving record, character, general reputation, personal characteristics and mode of living, whichever may be applicable. I understand I have the right to make a written request to McCullough Excavating within a reasonable period of time for additional information concerning the nature and scope of any investigation conducted. I also acknowledge receipt of the previous statement regarding investigative consumer reports.

EMPLOYMENT POLICIES: I understand that this application will remain active for consideration for six (6) months (180 days). If at the conclusion of this period, I want McCullough Excavating to continue to consider me for employment, I must reapply. I understand that as a condition of employment I agree to comply with McCullough Excavating’s employee policies and work rules, including but not limited to its confidentiality and conflict of interest policies.

EMPLOYMENT-AT-WILL: I understand that the McCullough Excavating is an “at-will” employer. As such, employment with McCullough Excavating may be terminated at the will of either party, with or without cause, and without prior notice. I understand that no supervisor or representative of McCullough Excavating, except appointed by the Owner and only when in writing (signed and dated by both parties), can enter into an employment contract, either written or verbal.

JOB FUNCTIONS: I attest that I can perform the essential functions of the job, with or without reasonable accommodation. I understand that under Indiana law, if I am a qualified individual who is disabled and requires an accommodation, I understand that it is my responsibility to request an accommodation within 182 days after the date I knew or reasonably should have known that an accommodation was needed.

STATUTE OF LIMITATIONS: I understand that as a condition of employment I agree to commence any action or suit relating to my employment relationship with McCullough Excavating within the lesser of the applicable statute of limitations or 182 calendar days after the date that I knew or should have known about the incident giving rise to the action or suit. Furthermore, I agree to waive any statute of limitation to the contrary.

I understand that my employment will not be considered unless this application is completed in its entirety.

Signature of Applicant

Date

MM slash DD slash YYYY

Name

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