Application For Employment It is our policy to comply with all applicable state and federal laws prohibiting discrimination in employment based on race, age, color, sex, religion, national origin, or other protected classification. Step 1 of 3 - Personal & Education 33% Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* If applying for a construction position, are you over 18 years old?* Yes No Are you authorized to work in the U.S. on an unrestricted basis?* Yes No How did you learn of this opening?* Have you worked here before?* Yes No Do you have a Current US Drivers License?* Yes No Is it a CDL? Yes No Are you related to anyone in our employ?* Yes No State name and department of relative Are there any hours, shifts or days you cannot or will not work?* Shift preferred:* * Part-Time Full-Time Are you willing to work overtime as required?* Yes No Have you ever been convicted of a felony?* Yes No (Conviction will not necessarily disqualify an applicant for employment.)Describe conditions of conviction: Positions applied For:* Click plus sign after the first row to add additional information.Wage or salary desired?* When can you start?* MM slash DD slash YYYY EducationHigh School Education: Name & Location of School* High School Diploma Obtained?* Yes No College/University EducationName & Location of SchoolYear GraduatedMajorDegree Click plus sign after the first row to add additional information.Click plus sign after the first row to add additional information.Other Training/Education Description Click plus sign after the first row to add additional information. WORK HISTORYMay we contact your present employer?* Yes No MOST RECENT EMPLOYERMost Recent Employer* Phone*Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date Started* MM slash DD slash YYYY Date Left* Starting Position* Position on Leaving* Starting Salary* Salary on Leaving* Name and Title of Supervisor* Description of Duties*Reason for Leaving* Previous EmployerPrevious Employer PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date Started MM slash DD slash YYYY Date Left MM slash DD slash YYYY Starting Position Position on Leaving Starting Salary Salary on Leaving Name and Title of Supervisor Description of DutiesReason for Leaving Previous EmployerPrevious Employer PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date Started MM slash DD slash YYYY Date Left MM slash DD slash YYYY Starting Position Position on Leaving Starting Salary Salary on Leaving Description of DutiesName and Title of Supervisor Reason for Leaving Previous EmployerPrevious Employer PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date Started MM slash DD slash YYYY Date Left MM slash DD slash YYYY Starting Position Position on Leaving Starting Salary Salary on Leaving Description of DutiesName and Title of Supervisor Reason for Leaving OTHER SKILLS OR QUALIFICATIONSIn addition to your work history what other experiences, skills or qualifications would especially fit you for work with Nesbitt Contracting?* MAINTENANCE AND EQUIPMENT EXPERIENCE & QUALIFICATIONSList Years of ExperienceDiesel Engine Tune-Up/Rebuilding Diesel Injection Equipment Gas Engine Tune-Up/Rebuilding General Car Repair Tire Service Tire Recapping Mold Wheel/Tire Balancing Machine Brakes Frame/Wheel Alignment Drive Line Components Air Conditioning Inspections Body Work Cooling Systems Electrical Repair Trailer Repair Engine Analyzer Electric Welder Oxyacetylene Welder Frame & Axle Straightening Equipment Spray Paint Gun DRIVER QUALIFICATIONSLICENSES - Drivers Licenses held in the past 3 years must be shown.STATELICENSE NO.CLASSENDORSEMENT(S)EXP. DATE Click plus sign after the first row to add additional information.A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No B. Has any license, permit or privilege ever been suspended or revoked? Yes No C. Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations? Yes No If you answered "Yes" to A, B, or C, give details below.DRIVING EXPERIENCEClick plus sign after the first row to add additional information.Class of Equipment (Straight Truck, Tractor and Semi-Trailer, Twine Trailers - LVC's, Other)Type of Equipment (Tank, Flat, Etc.)Dates From and ToApproximate Total Miles Click plus sign after the first row to add additional information.ACCIDENT REVIEW FOR PAST 3 YEARS STARTING WITH MOST RECENTDatesNature of Accident (Head-on, Rear-End, Overturn, etc.)FatalitiesInjuries Click plus sign after the first row to add additional information.TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS OTHER THAN PARKING VIOLATIONSLocationDateChargePenalty Click plus sign after the first row to add additional information.APPLICANT'S CERTIFICATION AND AGREEMENTI certify that the facts set forth in this Application for Employment are true and complete to the best of my knowledge. I understand that if I am employed, false statements, omissions or misrepresentations may result in my dismissal. I authorize the Company to make an investigation of any of the facts set forth in this application. I understand that, in the absence of a collective bargaining agreement governing the terms of employment, employment at this Company is "at will," which means that either I or the Company can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statute. All employment is continued on that basis. I understand that no supervisor, manager or executive of the Company, other than the president, has any authority to alter the foregoing.Applicant's Signature* Date* MM slash DD slash YYYY I understand that Nesbitt Contracting Co., Inc. / Century Materials, Inc. / Arizona Pavement Profiling, Inc. expressly forbid the use of alcoholic beverages while on duty or being under the influence of alcoholic beverages while on duty. I also understand that any use of illegal drugs or any abuse of prescription drugs on or off duty are also prohibited and will not be tolerated. Accordingly, I understand that I may be required, as a part of the application process, to submit a blood test or urine test for the purpose of determining that the applicant is not in violation of the above-stated policy. I understand that the test will be conducted by a qualified medical facility, to be selected by the company. Applicants may be required to pay for their pre-employment drug and alcohol screens prior to providing the sample. If the test turns out negative, the employee will reimbursed for his expense. Positive test results are non-refundableSigned* Date* MM slash DD slash YYYY AFFIRMATIVE ACTION INFORMATION FORMWe are an affirmative action government contractor. In compliance with government regulations we are required to record the number of applicants by age and sex. We ask that you indicate your race or national origin, date of birth and sex. This information will not be kept with your application and will be used only in accordance with federal and state regulations. YOU ARE NOT REQUIRED TO PROVIDE THIS INFORMATION. Your application for employment will be considered in the same manner whether or not you fill out this form.Gender Male Female Date of Birth MM slash DD slash YYYY Do you consider yourself to be Hispanic or Latino? Yes No If not, what race/races do you consider yourself to be? White Black or African American Native Hawaiian or Other Pacific Islander Asian American Indian or Alaska Native Two or more races (Not Hispanic or Latino) NameThis field is for validation purposes and should be left unchanged.
