Cullen Concrete Form Co

Cullen Concrete Form Company, Inc.
Cullen Concrete Pumping Service

22 Holmes Avenue • Northfield, NH 03276 • 603–286–8057

APPLICATION FOR EMPLOYMENT

We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, or any other legally protected status.

PLEASE PRINT
Position Applied For:	Date of Application:

Last Name:

First Name:

Middle Initial:

Address:

City:

State:

Zip Code:

Telephone Number:

Email Address:

Social Security Number: - -

Best time to contact you at home:

If you are under 18 years of age can you provide required proof of your eligibility for work? Yes No

Have you ever filed an application with us before? Yes No If yes, give date:

Have you ever been employed by us before? Yes No If yes, give date:

Do any of your friends or relatives, other than spouse work here? Yes No If yes, name and relationship:

Are you currently employed? Yes No

May we contact your present employer? Yes No

Are you prevented from becoming employed in this country because of citizen or immigration status? Yes No
Proof of citizenship or immigration status is required at time of application.

Date available for employment: Starting hourly rate or salary desired:

EDUCATION

School	Name and Address of School	Course of Study	Years Completed	Diploma or Degree
High School
Undergraduate College
Graduate/Professional
Other (Specify)

ADDITIONAL INFORMATION
State any additional information that may be helpful to us in considering your application including job related training and U.S. military service.

Are you able to perform the following job function with or without an accommodation? Laborer: picking up and moving, carrying 100 lb.
forms? Yes No

If you can perform the function with an accommodation, explain below how you would perform the tasks, and with what accommodations?

Were you ever seriously injured? Yes No (If yes, give details below.)

Have you been convicted of a felony or misdemeanor within the last 5 years? Yes No (If yes, give details below. You will not be denied employment solely because of a conviction record, unless the offense is related to the job for which you have applied.)

Note to Applicant: Do not answer the following question unless you have been informed about the requirements of the job for which you are applying.
Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the job or occupation for which you have applied? A review of the activities involved in such a job or occupation has been given. Yes No

EMPLOYMENT EXPERIENCE
Start with your present or last job. Include any job-related military service assignments and volunteer activities. Exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.

Employer:

Dates Employed
From	To
Hourly Rate or Salary
Start	End

Work
Performed

Address:

Telephone number:

Job title:

Supervisor:

Reason for leaving:

May we contact? Yes No

Employer:

Dates Employed
From	To
Hourly Rate or Salary
Start	End

Work
Performed

Address:

Telephone number:

Job title:

Supervisor:

Reason for leaving:

May we contact? Yes No

REFERENCES
Do not include family members or past supervisors.

Name	Phone Number	Best time to call	Occupation
1.
2.
3.

APPLICANT'S STATEMENT
I certify that answers given herein are true and complete.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

I understand and agree that I may be required to take one or more physical examinations as a condition of hiring or continued employment. I agree to consent to take such test(s) at such time as designated by the Company and to release the Company, its directors, officers, agents or employees from any claim arising in connection with the use of such test(s).

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Employer.

Electronic Signature: Your initials typed here state you have read the above and swear it to be true.