Employment Application

PERSONAL INFORMATION

Date:

Name:

Address:

City, State, Zip:

Phone #:

E-Mail Address:

SS#:

Are you authorized to work in the U.S.: YES NO

Are you presently employed: YES NO

May we contact your present & past employer (s): YES NO

Driver's License #:

State of:

Plumbing License #:

State of:

BACKGROUND INFORMATION

Have you ever been convicted of a felony?: NO YES

If yes, explain:

EDUCATION

Highest grade completed:

Did you graduate?: YES NO

School name:

Trade, business, or correspondence school?:

College or University?:

GENERAL

Do you have a complete set of hand tools?: YES NO

Do you have a B-Tank set up?: YES NO

Mode of transportation:

Vehicle make & model:

We are a drug free work place.
Would you be willing to be tested for drugs periodically?: YES NO

If no, please explain in detail:

PLEASE ANSWER THE FOLLOWING.
For each of these normal plumbing tasks, are you physically able to:

Lift a fixture or piece of equipment weighing 100 lbs?: YES NO

If not, please explain:

Bend, twist, kneel, stand, or reach overhead for extended periods of time?: YES NO

If no, please explain in detail::

Were you ever injured on or off the job?: NO YES

If yes, explain in detail:

In cases of an emergency, who should we notify?:

Phone #:

EMPLOYMENT HISTORY

Current or last job information:

Dates: Employer name:

Position: Salary:

Reason for leaving:

Second to last job information:

Dates: Employer name:

Position: Salary:

Reason for leaving:

Third to last job information:

Dates: Employer name:

Position: Salary:

Reason for leaving:

Additional information you would like to tell us:

I, , hereby affirm that all of the above information is correct to the best of my knowledge.

I understand that if I am employed, I will be on a 90 day probationary period and may be terminated at any time.

YES NO