Name Last: First: Middle:
Phone Number: Alternate Phone:
Drivers License Class:
City: State: Zip:
Are You 18 Years or Older? Yes No Email:
Are you legally authorized to work in the U.S.? Yes NoProof of identity and eligibility will be required upon hire.
What Foreign Languages do you speak fluently?
Have you been convicted of a felony or misdemeanor within the last 5 years?** Yes No
**You will not be denied employment solely because of a conviction record, unless the offense is related to the job for which you have applied.
I understand and agree that I may be required to take one or more: Physical examination; Drug screen; Physical Base Line as a condition of hiring or continued employment. I agree to consent to take such test(s) at such time as designated by the Company and to release the Company, its directors, officers, agents or employees from any claim arising in connection with the use of such tests. Yes No
Position: (See Job Descriptions)
Date You can start: Salary desired:
Are You Employed Now? Yes No:
If So May We Inquire of Your Present Employer? Yes No
Ever Worked for Smoky Hill Const. Before? Yes No
TRADE SCHOOL OR OTHER EDUCATION
*The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age.
Subjects of Special Study or Research Work
U.S. Military or Navel Service
Present Membership in National Guard or Reserves
(List Below Last Three Employers, Starting With The Last One First).
Name of Employer
Address of Employer
Salary Job Title
Reason for Leaving
Give the Names of Three Persons not Related to You, Whom You Have Known at Least One Year.
Business Years Acquainted
Can you Perform the Essential Functions of Your Job, With or Without a Reasonable Accommodation? Yes
(See Basic work requirements)
Voluntary EEO Self-Identification Form
The Company is an equal opportunity employer and does not discriminate against applicants or employees on the basis of race, color, religion, sex national origin, age, disability, veteran status, citizenship or any other characteristic protected by federal, state or local laws. The purpose of this form is to assist the Company in complying with required government record keeping and reporting requirements as well as affirmative action obligations, if applicable. This information is not part of your employment application and will not be considered in the employment/selection process. The information requested is voluntary and will be kept confidential. If you choose not to provide this information, you will not be subject to any adverse treatment. If you choose to provide the information, please complete the following:
Sex: Male Female
RACE/EthnicityAre you Hispanic or Latino? (A person of Cuba, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin regardless of race.)
If you answered “No” to “Are you Hispanic or Latino?” please indicate what race/ethnicity you believe yourself to be:
American Indian or Alaskan Native (Not Hispanic or Latino)- A person having origins in any of the original peoples of North or South American (including Central America) and who maintain tribal affiliation or community attachment.
Asian (Not Hispanic or Latino)- A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, china, India, Japan, Korea, Malaysia, Pakistan, the Philippines Islands, Thailand, and Vietnam.
Black or African American (Not Hispanic or Latino- A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino- A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
White (Not Hispanic or Latino- A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Two of More Races (Not Hispanic or Latino- All persons who identify with more than one of the above five races.
Referral Source:Newspaper Kansas Works Internet Ad Relative
Voluntary Veterans and Disability Self- Identification Form
Are you and individual with a disability? (You may be an individual with a disability if you have a physical or mental impairment, which substantially limits you in one or more major life activity, or have a record of having such impairment, or are regarded as having such impairment.)
Special Disabled Veteran
Vietnam Era Veteran
Recently Separated Veteran
Other Protected Veteran
Armed Forces Service Medal Veteran
I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.
I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you.
If hired, I understand that my employment is at-will and can be terminated at any time, with or without notice, for any reason at the option of the company or me. Should the company hire me, I agree to observe all the company’s policies, practices and procedures currently in existence and new or revised ones, which may be issued in the future.
Submit this application only if all answers are completely accurate. Refer to the following information:
A. Basic work requirements.
B. Job Descriptions.
Potential candidate for employment must authorize investigative reports