Step 1 of 5 0% Name* First Last Email Address* Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Cell Phone*FaxPosition(s) Applied For* Date You Can Start* MM slash DD slash YYYY Are you legally eligible for employment in the United States?* Yes No Do you have a valid driver's license?* Yes No Are you at least 18 years of age?* Yes No If you are not at least 18 years of age, how old are you?If you are not at least 18 years of age, do you have valid working papers? Yes No Have you ever filed an application with us before?* Yes No If yes, give date MM slash DD slash YYYY Have you ever been employed with us before?* Yes No If yes, give date MM slash DD slash YYYY Are you available for full time work?* Yes No Are you available to travel, via a method of transportation provided by you, to job sites within a 75 mile radius of Leeward's Corporate Office?* Yes No Are you able to perform all of the essential functions of the job that you have applied for with or without a reasonable accommodation?* Yes No Have you ever been convicted of, or pled guilty to, any felony or misdemeanor crime?* Yes No If you answered yes above, please list all crimes which you have been convicted of or pled guilty to and include the date of offense. Please note that you will not automatically be excluded from consideration based upon a criminal record. Your suitability for the position sought will be evaluated based upon the circumstances in order to determine whether the criminal record renders you unsuitable for the job. Have you been discharged or fired from any job that you have held within the past 10 years?* Yes No If you answered yes above, please describe the circumstances involved.* Please list the skills and/or qualifications which you feel would especially qualify you for the position for which you have applied.* Equipment Operators Only: Please enter the number of years of experience you have operating the following machinery:Bulldozer YearsLoader YearsSkid Steer YearsCrane YearsExcavator YearsOther Years CURRENT EMPLOYMENTEmployer's name* Date From – To* May we contact your present employer?* Yes No Current rate of pay*Immediate supervisor* Employer's address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Description of current positon and job duties* Has your employer taken any disciplinary action against you within the last two years?* Yes No If yes, explain the discipline and the reasons in detail.EDUCATIONHigh School* Number of years completed* University/college/trade school Number of years completed Major/Degree Other education FORMER EMPLOYERS (List below your last four employers; do not skip any employers.)Name, Address & Phone Number*Name of Supervisor* Date From – To* Salary or wage* Description of Job* Reason for Leaving* Name, Address & Phone NumberName of Supervisor Date From – To Salary or wage Description of Job Reason for Leaving Name, Address & Phone NumberName of Supervisor Date From – To Salary or wage Description of Job Reason for Leaving Name, Address & Phone NumberName of Supervisor Date From – To Salary or wage Description of Job Reason for Leaving MILITARY SERVICEBranch of Service Period of Active Duty (From – To) Date of Final Discharge Rank of Discharge REFERENCES (List three persons not related to you, whom you have known at least one year.)Name* Business Phone Number Address* Years Acquainted* Name* Phone Number Business Address* Years Acquainted* Name* Business Phone Number Address* Years Acquainted* Name* Business Phone Number Address* Years Acquainted* APPLICANT’S AUTHORIZATION AND CERTIFICATION PLEASE READ CAREFULLY I understand that providing false information on an application for employment is grounds for the Company to refuse to hire me, or to terminate my employment in the event that the misrepresentation is discovered after I have been hired. In submitting this application for employment, I authorize the Company to investigate all statements contained in it, and I understand that my current and/or former employers may be contacted to provide information concerning my suitability for employment, and that the references whom I have listed above will be contacted concerning my suitability for employment. I expressly authorize the Company to conduct such inquires and I release the Company and any responding parties from any and all liability associated with such inquiries. I understand and agree that I may be asked to undergo a post-offer, pre-employment medical examination, which will include a substance abuse test. The substance abuse test includes a breathalyzer and a urine sample. I understand that if I refuse to sign this employment application and or refuse my test, my application will not be considered further. I understand that if the initial breathalyzer test is positive, it will be followed by a second breathalyzer test. Additionally, I understand that if the urine test is positive, it will be followed by a confirmation test of the same urine sample. If the second breathalyzer or urine test is also positive, I understand that my application will not be considered further. I understand that in the event that I am hired, I will be hired as an at-will employee, and my employment may be terminated at any time, with or without cause, at the option of either the Company or myself. I understand that no representative of the Company except the President has any authority to enter into any legally binding employment agreement. I certify that I have read this entire employment application, including all information that I have provided on the application, and the entire statement set forth immediately above. I further certify that all of the information that I have provided on this employment application is true and correct.Applicant's Authorization and Certification Signature* Date* MM slash DD slash YYYY Referral Source: (Please check all that apply)* Advertisement Friend Government Agency Employee Name of Employee Private Employment Agency Walk In Internet Other Section BreakPlease list your current personal State Drivers License Number or permit:License Number / Permit Number* State* Expiration Date* Other than your current personal State Drivers licence number or permit number listed above, please list the last two States in which you held a personal State Drivers license number or permit number:License Number / Permit Number State Expiration Date License Number / Permit Number State Expiration Date Please list your current CDL/Permit #:CDL Number / Permit Number State Expiration Date Other than your current CDL/Permit # listed above, please list any CDL/Permit #s you have held in the last two years:CDL Number / Permit Number State Expiration Date CDL Number / Permit Number State Expiration Date Please list the types of Equipment (i.e. tractor, straight truck) and extent of experience with operation or each motor vehicle:Type of Equipment Years of Experience Type of Equipment Years of Experience Type of Equipment Years of Experience Please list all motor vehicle accidents in which you were involved during the last three years: Date of Accident Number of Injuries Number of Fatalities Description of Accident Did you receive any citation? If so, explain: Date of Accident Number of Injuries Number of Fatalities Description of Accident Did you receive any citation? If so, explain: Date of Accident Number of Injuries Number of Fatalities Description of Accident Did you receive any citation? If so, explain: Has your license, permit or privilege to operate a motor vehicle ever been denied, revoked, or suspended? Yes No If so, please describe all facts and circumstances. Section BreakVarious government agencies require periodic reports of Equal Employment compliance and Affirmative Action. This information is not utilized in the employment decision, is kept separate and confidential, and is used for statistical analysis and compliance only. A refusal to provide this information will not subject you to any adverse treatment.Name* Please check all appropriate boxes* Male Female White Asian Native Hawaiian or Other Pacific Islander American Indian or Alaskan Native Hispanic or Latino (white race only) Hispanic or Latino (all other races) Disabled – Physical or mental impairment which substantially limits one or more of your life activities. Disabled Veteran – One entitled to disability compensation of 30% or more under laws administered by the Veterans Administration, or veterans discharged from active duty for a disability incurred or aggravated in the line of duty. Vietnam Era Veteran – A person who served on active duty for more than 180 days anytime between August 5, 1964 and May 7, 1975 and was discharged or released other than dishonorably, or was discharged or released from active duty for a service connected disability if any part of such active duty was performed between August 5, 1964 and May 7, 1975. Other Veteran – Veteran who served on active duty during a war or in a campaign or expedition for which a campaign badge has been authorized. (For a specific list, refer to www.opm.gov/veterans/html/vgmedal2.htm or contact the Human Resource Department.) Signature* Today's Date* MM slash DD slash YYYY
