JOB APPLICATION
Today’s Date____________________
Name______________________________________________________
Address____________________________________________________
City________________State_______________Zip Code_____________
Home Phone__________________Work Phone_____________________
Social Security Number____________________Date of Birth__________

APPLICANT NOTE: This application form is intended for use in evaluating your qualifications for employment. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment, terminating employment. Additional testing of job-related skills and for the presence of drugs in your body may be required prior to employment.

JOB-RELATED SKILLS: NOTE: Do not fill out any part of this section you believe to be non-job related.

Yes No If the job requires, do you have the appropriate valid drivers license?
Name on license_____________________DL#__________Type_________
State of Issue____________

Yes No Have you had any moving violations? Please describe.________________

Yes No Do you have any other skills, licenses or certificates that may be job-related or that you feel would be of value to this job or company. (please list) ____________________________________________________________

Yes No Do you have a current Utah Electrician License (circle one)
Apprentice Journeyman Master

Yes No Have you been given a job description or had the requirements of the job explained to you?

Yes No Do you understand these requirements?

Yes No Can you perform the requirements of this job with or without reasonable accommodation?

Yes No Will you work Overtime on occasion if necessary?

Yes No Do have any on-going obligations such as school, another job, or personal commitments that might affect your work schedule here?

Hourly Wage You Expect $_______________

Date available for work: _______________

List any prior Electrical Experience (commercial, residential, industrial)___________________

Education:
School most recently attended:_________________________________________________________

Highest Grade Completed:_______

If your school records are under a different name than above, please enter that name:______________

Previous Employer(s):

COMPANY NAME________________________________PHONE_____________________

CITY_____________________________________________________STATE_____________

DATES EMPLOYED FROM: TO:______________
JOB TITLE_______________________SUPERVISOR NAME____________________________

DUTIES________________________________________________________________________

SALARY PER (Hour, Week, Month)

REASON FOR LEAVING _________________________________________________________
Current Employer(s):

COMPANY NAME________________________________PHONE_____________________

CITY_____________________________________________________STATE_____________

DATES EMPLOYED FROM: TO:______________
JOB TITLE_______________________SUPERVISOR NAME____________________________

DUTIES________________________________________________________________________

SALARY PER (Hour, Week, Month)

REASON FOR LEAVING _________________________________________________________

REFERENCES: Include only individuals familiar with your work ability. Do not include relatives.

NAME ADDRESS/PHONE YEARS KNOWN/RELATIONSHIP

1.

2.

CERTIFICATION AND RELEASE: I certify that I have read and understand the applicant note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any of this information. I authorize all former employers, person, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said person, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs I prohibited during employment. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.

SIGNATURE:______________________________________ DATE:________________________________