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Delta Contracting
Pavement Profilers
APPLICATION FOR EMPLOYMENT
Fields marked with * are required.
Personal Information
First Name
*
Middle Name
Last Name
*
Address
*
City
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State
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AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
*
Home Telephone
Mobile Number
Email Address
Social Security Number
Have you ever applied for employment with us?
*
Yes
No
If yes, Month and Year
Position Desired
Are you a U.S. Citizen?
*
Yes
No
Are you legally eligible for employment in the United States?
*
Yes
No
Are you at least 18 years of age?
*
Yes
No (Employment is subject to verification of age)
Have you been convicted of a crime in the past ten years, excluding misdemeanors and summary offenses, which has not been annulled, expunged or sealed by a court?
*
Yes
No
If yes, describe in full:
Referred by (one name only)
List names of relatives and friends working for us
Are you currently bound by any contract or agreement that would legally prevent you from being employed with us?
*
Yes
No
Special training or skills (languages, machine operation, etc.)
List any Memberships in Professional or Civic Organizations (Exclude those which may disclose your race, color, religion or national origin)
Apart from absence for religious observance, are you available for full-time work?
*
Yes
No
If not, what hours can you work?
Will you work overtime if asked?
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Yes
No
Amount of Pay Expected
When will you be available to begin work?
Education Information
High School Name and Location
# Years Completed
Did you graduate?
*
Yes
No
Business/Trade/Technical School Name and Location
Degree/Course of Study
# Years Completed
Did you graduate?
Yes
No
College Name and Location
Degree/Course of Study
# Years Completed
Did you graduate?
Yes
No
Employment Information
List current and previous employers
1
Company Name
*
Address
*
Job Title
*
Describe Your Work/Duties
*
Name of Supervisor
*
Telephone Number
*
Employment Dates (month/year)
*
Start
End
Weekly Pay
Reason for Leaving
*
2
Company Name
Address
Job Title
Describe Your Work/Duties
Name of Supervisor
Telephone Number
Employment Dates (month/year)
Start
End
Weekly Pay
Reason for Leaving
3
Company Name
Address
Job Title
Describe Your Work/Duties
Name of Supervisor
Telephone Number
Employment Dates (month/year)
Start
End
Weekly Pay
Reason for Leaving
Do Not Contact
We may contact the employers listed above unless you indicate those you do not want us to contact.
Employer Number(s)
Reason
Military Service
Did you serve in the U.S. Armed Forces?
*
Yes
No
If yes, in what Branch?
Describe any training received relevant to the position for which you are applying:
EQUAL OPPURTUNITY EMPLOYER
VOLUNTARY QUESTIONNAIRE (FOR EEO PURPOSES ONLY)
We as an employer wish to voluntarily comply with various laws and regulations which require us to file annual statistical reports on applicants for employment. In addition, we wish to voluntarily comply with the various laws and regulations which protect the handicapped, disabled veterans and veterans who served on active duty during the Vietnam-era for more than 180 days. Submission of this information by you is voluntary. Please be assured that you will not be subject to any adverse treatment if you do not provide this information.
Applicants Identifying Themselves as Handicapped
Are you a handicapped individual or do you have any physical condition or handicap which may limit your ability to perform the position(s) for which you apply?
Yes
No
If yes, do you possess or can we provide you with any special methods, skills, or procedures which might qualify you for positions you might not otherwise be able to do because of your handicap?
You are not required to provide the above information concerning a handicap. If you do, it will be kept confidential, with the following exceptions:
Supervisors may be informed if accommodations are necessary or if your work duties are restricted.
Government representatives may be provided information in compliance with various laws and regulations.
Applicants Identifying Themselves as Disabled or Vietnam-Era Veterans
Are you a disabled veteran?
Yes
No
Applicants Identifying Their Sex and Race
Sex Classification
Male
Female
Race Classification
White (Not of Hispanic Origin)
Black (Not of Hispanic Origin)
Hispanic
Asian or Pacific Islander
American Indian or Alaskan Native
Date
Prospective employees will receive consideration without discrimination because of race, creed, color,
sex, age, national origin, handicap or veteran status.
Challenge
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