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Employment Application

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DateToday's Date
First Name
Last Name
Middle Name
Street Address
City
State
Zip
How long have you been at this address?
Phone Number
Alt. Phone
If under 25, please list age.

What hours can you work?

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
How many hours can you work weekly?
Can you work nights?
Emloyment Desired
When are you available to start work?
Have you sustained any injury that may prohibit you from working in a construction environment?(back or neck injury, heat stroke, etc.)

Please fill out to the best of your ability.

High School Name
Location
Did you graduate?
College Name
Location
# of Years Completed
Major & Degree
Bus. or Trade School
Location
# of Years Completed
Major & Degree
Professional School
Location
# of Years Completed
Major & Degree
Have you ever been convicted of a crime?
If yes, please explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.
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Have you ever been in the armed forces?
Are you now a member of the National Guard?
Work Experience

Please include work experience for the past ten years, beginning with your most recent job held. If you were self-employed, give firm name. Attach resume at end for additional work experience if necessary.

Employer Information(Name, Address, Phone Number)
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Supervisor Name
Salary
Start Date
End Date
Reason for leaving.(be specific)
What was your job description, duties and/or responsiblities?
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Employer Information(Name, Address, Phone Number)
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Supervisor Name
Salary
Start Date
End Date
Reason for leaving.(be specific)
What was your job description, duties and/or responsiblities?
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Employer Information(Name, Address, Phone Number)
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Supervisor Name
Salary
Start Date
End Date
Reason for leaving.(be specific)
What was your job description, duties and/or responsiblities?
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May we contact your present employer?
Do you have a driver's license?
Type of DL?
What is your means of transporation to work?
Have you had any accidents during the past 3 years?
How many?
How many moving violations have you had during the last 7 years?
Computer Skills
Typing WPM(Word per minute)
Computer Familiarity
List all computer applications that you know:
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References

Please list two references other than relatives or previous employers.

Name
Position
Company
Address(City, State, Zip)
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Telephone

Name
Position
Company
Address(City, State, Zip)
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Telephone
Employee EEO Self-Identification Section

We are an Affirmative Action, Equal Opportunity Employer. Our employment decisions are made without regard to race, color, religion, gender, national origin, age, disability, marital status, veteran or military status, or any other legally protected status. The purpose of this Employee EEO Self-Identification Section is to comply with federal government record-keeping and reporting requirements. Periodic reports are made to the government on the following information. The data you provide on this section will be kept confidential and use solely for analytical and reporting requirement purposes. This section is processed and maintained separately from your personnel file and is not used to make decisions about the terms and conditions of your employment. Completion of this section is optional and voluntary. We appreciate your assistance.

Position TitleYour position title.
Last 4 of Social Security
Race or EthnicityPlease select one.
Sex or GenderPlease select one.
Voluntary Self-Identification of Veteran Status

If you are a disabled veteran it would assist us if you tell us whether there are accommodations we could make that would enable you to perform the essential functions of the job, including special equipment, changes in the physical layout of the job, changes in the way the job is customarily performed, provision of personal assistance services or other accommodations. This information will assist us in making reasonable accommodations for your disability.


Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information provided will be used only in ways that are not inconsistent with the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended.


The information you submit will be kept confidential, except that supervisors and managers may be informed regarding restrictions on the work or duties of disabled veterans, and regarding necessary accommodations; first aid and safety personnel may be informed, when and to the extent appropriate, if you have a condition that might require emergency treatment; and Government officials engaged in enforcing laws administered by the Office of Federal Contract Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed.

Veteran StatusSelect all that apply.
Voluntary Self-Identification of Disability

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities. To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying to a job, any answer you give will be kept private and will not be used against you in any way.


If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.


You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history of such an impairment or medical condition.


Disabilities include, but are not limited to:

Blindness Autism Bipolar Disorder Post-traumatic stress disorder (PTSD)
Deafness Cerebral Palsy Major Depression Obsessive Compulsive Disorder
Cancer HIV/AIDS Multiple Sclerosis (MS) Impairments requiring the use of a wheelchair
Diabetes Schizophrenia Missing limbs or partially missing limbs Intellectual disability (previous called mental retardation)
Epilepsy Muscular dystrophy
Disability StatusPlease select one.

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process, using a sign language interpreter, or using specialized equipment.


By typing your name into the box below, you certify that any voluntary claims you made in this section are true, and that you have read and understood the notices regarding voluntary self-identification of race, ethnicity, veteran status, and disability.

Electronic Signatureyour full name
Date of Signatureof appointment
An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying. Also, explain any lapses in work.
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If you need to upload more work history or feel as though we've left something uncovered, please upload your resume.

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It’s a fact; concrete is the most used building material in the world. More than brick, wood, steel, or anything else. It’s what businesses, homes, and dreams are built on. Here at Columbia County Concrete, we don’t take that lightly. We see it as a privilege, and consider it an honor to develop communities, and help cities grow…one load of concrete at a time.

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