Employment Application Form

Name*
First Last
Home Phone*
Cell Phone*
Email*
Address*
Street Address Address Line 2 City State ZIP Code

Employer History - Employer #1
Company Name*
Company City*
Job Title*
Job Duties*
Start Date*
Date Format: MM slash DD slash YYYY
End Date*
Date Format: MM slash DD slash YYYY
Reason for Leaving*
Ending Hourly Wage
May we contact this employer?*
- Yes
- No
Supervisor Name*
Supervisor Phone*
Employer History - Employer #2
Company Name*
Company City*
Job Title*
Job Duties*
Start Date*
Date Format: MM slash DD slash YYYY
End Date*
Date Format: MM slash DD slash YYYY
Reason for Leaving*
Ending Hourly Wage
May we contact this employer? #2*
- Yes
- No
Supervisor Name*
Supervisor Phone*
Employer History - Employer #3
Company Name*
Company City*
Job Title*
Job Duties*
Start Date*
Date Format: MM slash DD slash YYYY
End Date*
Date Format: MM slash DD slash YYYY
Reason for Leaving*
Ending Hourly Wage
May we contact this employer? #3*
- Yes
- No
Supervisor Name*
Supervisor Phone*

Certification and Authorization
I authorize investigation of all statements contained herein and the employers 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 the company from all liability for any damage that may result from utilization of such information. 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. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act and other relevant Federal, State or Local laws. I hereby consent and agree that my driver's license information may be given to Sierra Asphalt Inc.'s insurance agent, Capitol Division of InterWest Insurance Services, Inc. A record will be obtained from the Department of Motor Vehicles for underwriting purposes for automobile insurance for Sierra Asphalt Inc. I hereby authorize Capitol Division of InterWest Insurance Services, Inc. to release my driving record to Sierra Asphalt Inc. Consent to be kept on record for five years after employment ceases. I understand that nothing in this employment application, the granting of an interview, or my subsequent employment with the Company is intended to create an employment contract between myself and the Company under which my employment could be terminated only for cause. On the contrary, I understand and agree that, if hired, my employment will be terminable "at will" and may be terminated by me or the Company at any time and for any reason. I understand that no person has the authority to enter into any agreement contrary to the foregoing. If employed, I understand I will be required to provide original documents verifying my identity and right to work in the United States under the Immigration Reform and Control Act of 1986. The documents provided will be used for completion of Form I-9.
Consent*
I agree to the policy.
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Phone
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Employment Application Form

Step 1 of 4

Employer History - Employer #1

Employer History - Employer #2

Employer History - Employer #3

Certification and Authorization