Employment Application - Brown Heating and Cooling

BROWN HEATING & COOLING CO., INC.
APPLICATION FOR EMPLOYMENT
It is the policy of Brown Heating & Cooling Co., Inc. to provide equal employment
opportunities without regard to race, color, religion, sex, national origin, age, disability or
any other condition protected by law. No question on this application is asked for the
purpose of limiting or excluding any applicant’s consideration for employment because
of his or her race, color, religion, sex, national origin, age, disability or any other
condition protected by law.
Please fill out this Application in its entirety. Use N/A when not applicable.
PERSONAL INFORMATION
Name _________________________________________________________________
Address________________________City_______________State_____Zip___________
Telephone #
________________________Date of Birth _______________________
Social Security # ______________________ Driver’s License # ___________________
Type of Work Desired ____________________________________________________
Wage Expected ______________________ Date Can Start ______________________
Have you ever applied to or worked for this Company? Yes ________ No ___________
If so, When, Position Held _________________________________________________
If you have relatives employed by this company, please give names:
______________________________________________________________________
Desire Full or Part-time Work: ______________________________________________
Are you either a U. S. citizen or legally authorized to work in the United States?
Yes _______________ No ______________
(Your will be required to provide proof of citizenship or right to work status at time of
hire)
Have you ever been convicted of a crime? Yes ________ No _________
What Offense? Where? When?______________________________________________
______________________________________________________________________
EDUCATION
Circle Highest Grade Completed:
Grade School/High School 1 2 3 4 5 6 7 8 9 10 11 12
College/Graduate School
1 2 3 4 5 6
High School:
Name _____________________________ Location _______________________
Major Field ________________________ Degree _________________________
Dates Attended _____________________________________________________
College:
Name ____________________________ Location ________________________
Major Field ________________________ Degree _________________________
Dates Attended _____________________________________________________
Graduate School:
Name ___________________________ Location _________________________
Major Field _______________________ Degree __________________________
Dates Attended ____________________________________________________
Technical or Vocational School
Name _________________________ Location ___________________________
Major Field _____________________ Degree ____________________________
Dates Attended _____________________________________________________
Type
Professional Licenses and/or Certifications
Organization/State Issued
Date Issued
Number
________________________________________________________________
________________________________________________________________
(2)
Previous Work Experience
Present or last Employer: _____________________________________________
Address: _________________________________________________________
Telephone # _________________ Date of Employment _____________________
Position/Duties ___________________________________ Salary: ___________
Reason for Leaving: _________________________________________________
_________________________________________________________________
Employer: ________________________________________________________
Address: _________________________________________________________
Telephone # _________________ Date of Employment _____________________
Position/Duties ____________________________________ Salary: ___________
Reason for Leaving __________________________________________________
_________________________________________________________________
Employer: _________________________________________________________
Address: __________________________________________________________
Telephone # _________________ Date of Employment ______________________
Position/Duties ____________________________________ Salary ____________
Reason for Leaving ___________________________________________________
__________________________________________________________________
(3)
Military Service
Were you in the U.S. Armed Forces? ___________________________________
If yes, what branch? _________________________________________________
Date of duty: From _________________________ To ______________________
Rank of Discharge? __________________________________________________
Special Training or Duties while in military __________________________________
__________________________________________________________________
Are you currently a member of a reserve unit? _______________________________
Personal References
(Do not list relatives or former employers)
Name
Address
Telephone #
_________________________________________________________________
_________________________________________________________________
Applicant Certification
I certify that all information given on this application is true, correct, and complete. I
understand that misrepresentation or omission of facts will be cause for cancellation of
my consideration for employment, or dismissal, if employed. I authorize any inquiry to
be made on any information contained in this application, if I am considered for
employment.
I understand that this is an application for employment and that no employment contract
is being offered; and I understand that if employed, such employment is for an indefinite
period and is subject to change in wages, benefits, and operating policies.
I further understand that an offer of employment will be conditioned upon the successful
completion (if Brown Heating & Cooling chooses) of a physical examination, a MVR
(motor vehicle report), a background check, a criminal search, a previous employer
review, a credit report, a workers compensation report, a drug test and that continued
employment will be subject to the terms of the Company’s Drug and Alcohol Policy.
Signature:________________________________________ Date:______________
This application will remain active for ______ days.
Physical and Medical Information
In responding to the following questions, please refer to the job description for the
position for which you are seeking employment. **
Do you have any physical or mental condition which would substantially interfere with
your ability to perform the essential duties of the job for which you have applied or for
which you will need reasonable accommodation? YES_________ NO ________
If yes, please describe:
________________________________________________________________
________________________________________________________________
________________________________________________________________
Name, address, and phone number of physician having records and /or knowledge of
your medical history.
Name ________________________________Phone# _______________________
Address ____________________________________________________________
May we contact your physician for information on your medical history? _____________
Will you authorize, if necessary, a release of your medical records to assist us in
determining your fitness to perform any physical activities related to the job(s) for which
you are applying? YES_______________
NO ____________
** The responses to these questions will not be taken into consideration until after a
conditional job offer has been made.
Emergency Notification
Name: ___________________________________________________________
Address:__________________________________________________________
__________________________________________ Phone # _______________
(5)
RELEASE AUTHORIZATION
In connection with my application for employment, I understand that several consumer
reports may be requested and may include information as to my character, work habits,
credit, academic credential verification, job performance, experience and reasons for
termination. Further, I understand that you may be requesting information concerning
my workers’ compensation claims, motor vehicle operations history and criminal history
from various private and public sources along with other public records that are available.
I HEREBY AUTHORIZE AND RELEASE FROM ALL LIABILITY, WITHOUT
RESERVATION, BROWN HEATING AND COOLING/SENTRY
LINK/EMPLOYMENT SCREENING SERVICES AND ANY LAW
ENFORCEMENT AGENCY, ADMINISTRATOR, STATE/FEDERAL AGENCY,
INSTITUTION,INFORMATION SERVICE BUREAU, EMPLOYER,
EMPLOYEE, INSURANCECOMPANY OR PERSONS GATHERING OR
FURNISHING THE ABOVE INFORMATION.
I further acknowledge that a telephone facsimile (fax) or photographic copy of this
release will be as valid as the original. According to the Fair Credit Reporting Act, I am
entitled to know if employment will be and is ultimately denied because of information
obtained by my prospective employer or from a consumer reporting agency. If so, I will
be so advised by this employer and be given the name of the agency or source of
information.
Print Name: ____________________________________________________________
Last
First
Middle Initial
Maiden/Previous Name(s)__________________________________________________
Date of Birth______________ Social Security Number __________________________
Address _______________________________________________________________
Driver’s License # _____________________________ State Issued_______________
(Necessary for Motor Vehicle Reports)
______________________________________________________________________
Applicant’s Signature
Today’s Date
TO APPLICANTS FOR EMPLOYMENT AT BROWN HEATING & COOLING
Due to the requirements made by the State of Alabama’s Workman’s
Compensation and Brown Heating and Cooling’s Vehicle Insurance Company, we are
required to do drug testing and motor vehicle reports, on all employees and applicants for
employment.
Therefore, a charge of $45.00 for drug testing is required upon approval for
employment. If report is acceptable, a total refund will be issued after thirty (30) days of
employment.
I understand the information as stated above and agree to pay $45.00 upon consideration
for employment.
Signed: ________________________________ Date:____________________
IF YOU ARE BEING HIRED THROUGH A TEMP AGENTCY, THEY WILL DO
THE DRUG TESTING IF YOU ARE CONSIDERED FOR HIRE.
OFFICE PERSONAL DO NOT DRIVE COMPANY VEHICLES AND THEREFORE
NO MOTOR VEHICLE REPORT IS REQUIRED.