Employment Application

You can fill out the below application below or print a PDF formatted application by downloading it from the link
to the right and then mail it to: P.O. Box 37, 164 S. 1st Street - Blair, NE 68008

First Name

Middle Name

Last Name

Day Phone

Other Phone

Current Address

Street

State

City

Zip

Applying for:

How many hours can you work per week?

Date Available

Rate of Pay Expected

From:

To:

Where:

Rate of Pay:

Position:

Reason for leaving:

Names of relatives employed by this company:

Are you currently employed?

 Yes No

If you are currently employed, may we contact
your present employer?

 Yes No

Are you at least 18 years old?
(If under 18, hire is subject to verification
that you are of minimum legal age.)

 Yes No

If hired, can you present evidence of your U.S. citizenship or
proof of your legal right to live and work in this country?

 Yes No

Have you ever been convicted of a criminal offense
felony or serious misdemeanor?

 Yes No

If YES, please explain fully on a in the space below.

Conviction of a crime is not an automatic bar from employment.
All circumstances will be considered.

Have you ever worked for this company under another name?

 Yes No

If so, what name?

Physical demands of roofing work such as lifting repeatedly over 100lb., twisting, and bending are part of the job. Do you have any physical limitations that would restrict your ability to perform this kind of work?

 Yes No

If yes, describe the functions that cannot be performed.

(Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Hire may be subject to passing a medical examination, and to skill and agility tests.)

If the job requires, do you have a valid driver’s license?

 Yes No

License #

Type:

State Issue:

Select the highest grade completed:

Grade School:

select...123456789101112

College:

select...01234

Do you speak, write or understand any foreign languages?

 Yes No

If yes, which languages?

List below all present and past employment, starting with your most recent employer. Account for periods of unemployment.

Employer

Street

City

State

Zip

Telephone

Wage

Position & Duties

From

To

Reason for Leaving

Employer

Street

City

State

Zip

Telephone

Wage

Position & Duties

From

To

Reason for Leaving

Employer

Street

City

State

Zip

Telephone

Wage

Position & Duties

From

To

Reason for Leaving

List specific training in construction work or roof mechanics

Automotive Shop:

Indicate Training and Experience in the Following:	Formal Training	Years of Experience	Area	Formal Training	Years of Experience
Drive Line Components	Yes No		Body Work	Yes No
Diesel Engine Tune-up and Rebuild	Yes No		Frame and Wheel Alignment	Yes No
Gas Engine Tune-up and Rebuild	Yes No		Electrical Repair	Yes No
Tire Service	Yes No		Brakes	Yes No
Trailer Repair	Yes No		Cooling System	Yes No
Diagnostic Equipment	Yes No		General Car Care	Yes No
Inspections (St./Federal)	Yes No

Indicate Training and Experience in the Following:	Formal Training	Years of Experience	Area	Formal Training	Years of Experience
Electric Welder (Mig/Stick)	Yes No		Press Break	Yes No
Oxyacetylene Welder	Yes No		Shear	Yes No
Paint Spray Gun	Yes No		Pittsburgh Machine	Yes No
Magnetic Crack Detector	Yes No		Drill Press	Yes No
Engine Analyzer	Yes No		Rivet Machines	Yes No
Noise Measuring Equip.	Yes No		Punch Press	Yes No
Table Saw	Yes No		Automatic Break	Yes No
Compressor	Yes No		Skill Saw	Yes No

Indicate Training and Experience in the Following:	Formal Training	Years of Experience	Area	Formal Training	Years of Experience
Roof Cutter	Yes No		Motorized Conveyor	Yes No
Power Broom	Yes No		Chop Saw	Yes No
Power Lugger	Yes No		Bench Grinder	Yes No
Gravel Buggy	Yes No		Motorized Hoist	Yes No
Bulk Asphalt Tank	Yes No		Generator	Yes No
Asphalt Kettle	Yes No		Circular Saw	Yes No
Rocker	Yes No		Power Sprayer	Yes No
Spud Machine	Yes No		Bobcat	Yes No
Reciprocating Saw	Yes No		Hammer drill	Yes No

List types of platform experience and number of years of each

List platform equipment you can operate:
(Fork truck, Lull, Scissor Lift, etc.)

List formal training and experience with scaffolding:

I understand that I am being hired as an at will employee.