Download Employment Application - DAB Constructors, Inc.

(PLEASE PRINT )
D.A.B. CONSTRUCTORS INC.
“AN EQUAL OPPORTUNITY EMPLOYER”
P.O. BOX 1589, INGLIS, FLORIDA 34449 (352) 447-5488
APPLICATION FOR EMPLOYMENT
1. Job For Which Application is Filed
______________________________
FOR OFFICE USE ONLY
Start Date: ______________________
Position: _______________________
Pay Rate: _______________________
Date: ________________________
2. Name _________________________________ 3. Soc. Sec. No. _______________________ 4. Date of Birth ______________
5. Address ________________________________ City/ State ____________________________ Zip Code ___________________
6. Telephone (Home)________________________ 7. Date Available for Work ___________________________________________
8.
Firm Name
Last Three Employers
Date Month/Year
Job
Address
Salary
Reason for Leaving
From:
To:
From:
To:
From:
To:
May these employers be contacted? ____ Yes ____ No
9.
References ( Do not list relatives or former employers)
Address
Occupation
Name
Yrs. Acquainted
10. Employed by this company before? ____Yes ____ No If yes when? _________________________________________________
11. Relatives employed by this Company (Name) ___________________________________________________________________
12. High School Graduate? ____Yes ____ Attend College ____ Yes ____ No
College Graduate? ____ Yes ____ No Degree __________________________________________________________________
Special School Attended : (Describe) __________________________________________________________________________
Other Skills (Describe ) _____________________________________________________________________________________
Military Service: Branch ___________________ from ____________ to _____________ Type Discharge ___________________
13. Drivers License ____ Yes ____ No
License # ________________________ Chauffer License # ________________________
14. Previous Workmen’s Compensation Claims (Explain) _____________________________________________________________
___________________________________________________________________________________________________________
15. In case of Emergency Notify __________________________________________ Phone No. _____________________________
STATEMENT BY APPLICANT: I hereby authorize my former employers to furnish information concerning my work performance and evaluation. I also release them and their company
form all liability for any damage whatsoever for issuing same. I also authorize the company to request, at its option, a special investigative report based on personal interviews with third parties. In the
event I am employed by the company and I am terminated within 30 days from my first work day for any reason other than lay off for lack of work, the cost of my employement physical will be deducted
from my last pay check.
I further agree to the following: Any misstatement or commission of material facts in the application is cause for dismissal should I be hired by the Company. In the event I am hired, I understand and
agree to the following:
1. I shall be considered as a temporary a period of 3 months from my first working day and may be discharged or laid off before the expiration of that period, without recourse, for unsatisfactory
performance.
2. The company may issue certain items of equipment to me. I accept the responsibility for the maintenance and safe keeping of the equipment and agree to a deducti on form my last pay check for the
cost of all equipment not returned to the company upon my termination.
3. I hereby enroll for all of the insurance benefits for which I am eligible or may become eligible, including dependent group heath and accident insura nce, and authorize the deduction form my earnings
the contributions required to maintain the coverage. (If employee does not wish dependent coverage, delete phrase “including dependent group health and accident insurance.”)
4. All statements on this form are true and correct to the best of my knowledge. I understand that any misstatement or omission of material facts is cause for termination.
DATE: ______________________
EMPLOYEE SIGNATURE ______________________________________________________
D.A.B. CONSTRUCTORS, INC.
PLEASE NOTE: THIS IS A VOLUNTARY QUESTIONNAIRE
EQUAL EMPLOYMENT OPPORTUNITY SURVEY
TO ALL APPLICANTS: THE FOLLOWING INFORMATION IS REQUESTED TO AID THE
STATE OF FLORIDA IN ITS COMMITMENT TO EQUAL EMPLOYMENT OPPORTUNITY.
YOUR APPLICATION WILL NOT BE REJECTED BECAUSE OF YOUR RACE, COLOR, SEX,
RELIGION, CREED, HANDICAP, NATIONAL ORIGIN, POLITICAL BELIEFS OR AGE, EXCEPT
AS PROVIDED BY LAW.
SOCIAL SECURITY NUMBER: ________/_____/_______
DATE OF BIRTH: _____/____/____
SEX: ______MALE _____FEMALE
REFERRAL SOURCE: _____ADVERTISEMENT ______ WALK IN
_____ EMPLOYEE REFERRAL _____ EMPLOYMENT AGENCY _____ OTHER
POSITION(S) FOR WHICH APPLYING
1. ____________________________________
2. ____________________________________
RACIAL / ETHNIC DATA
PLEASE IDENTIFY YOURSELF IN TERMS OF THE RACIAL / ETHNIC GROUPS BELOW:
(CHECK ONLY ONE)
______HISPANIC: ALL PERSONS OF MEXICAN, PUERTO RICAN, CUBAN, CENTRAL OR
SO. AMERICAN, OR OTHER SPANISH CULTURE OR ORIGIN, REGARDLESS OF
RACE.
______ASIAN OR PACIFIC ISLANDER: ALL PERSONS HAVING ORIGINS IN ANY OF THE
ORIGINAL PEOPLES OF THE FAR EAST, SOUTHEAST ASIA, THE INDIAN
SUBCONTINENT OF THE PACIFIC ISLANDS. THIS AREA INCLUDES, FOR
EXAMPLE: CHINA, JAPAN, KOREA, THE PHILIPPINE ISLANDS AND SAMOA.
______AMERICAN INDIAN OR ALASKAN NATIVE: ALL PERSONS HAVING ORIGINS IN ANY
OF THE ORIGINAL PEOPLES OF NORTH AMERICA, AND WHO MAINTAIN
CULTURAL IDENTIFICATION THROUGH TRIBAL AFFILIATION OR COMMUNITY
RECOGNITION.
______BLACK: (NOT OF HISPANIC ORIGIN) ALL PERSONS HAVING ORIGINS IN ANY OF
BLACK RACIAL GROUPS OF AFRICA.
______WHITE: (NOT OF HISPANIC ORIGIN) ALL PERSONS HAVING ORIGINS IN ANY OF
THE ORIGINAL PEOPLES OF EUROPE, NORTH AFRICA, OR THE MIDDLE EAST.
______OTHER: (SPECIFY) _____________________________________________________
_____________________________________________________
APPLICANT DRUG TESTING RELEASE
APPLICANT DRUG TESTING CONSENT AND RELEASE
This form must be completed when employee is given conditional job offer.
Pursuant to my application for employment, I understand that all job offers are
expressly conditioned upon submitting to and passing a drug test to detect the presence
of illegal drugs or alcohol use. I hereby consent to submit to a urinalysis or other tests
as required by D.A.B. CONSTRUCTORS, INC, (the Company) for the purposes of
testing for the presence of illegal drugs or alcohol abuse. I agree that a clinic or
laboratory approved by the Florida Agency for Health Care Administration may collect
and test any specimens I provide for these tests. I further agree to authorize the
release of the results of these tests to the Medical Review Officer, employed or retained
by the Company, to the DRUG FREE OFFICER of the Company, and to such other
management personnel as my require this information on a need to know basis.
However, my understanding is that any information derived from these tests will be
confidential between the laboratory, the DRUG FREE OFFICER of the company and
the Medical Review Officer, except as otherwise provided by law, or if I place the test or
its results in issue in any administrative, legal, or other proceeding.
I further agree to release and hold the Company and its agents, employees and
assigns, including the laboratory collecting and conducting these tests, harmless from
any liability arising in whole or in part out of the collection or testing of the specimens I
provide or from the use of the information derived from these tests in consideration of
my employment application.
I have carefully read the Consent and Release form and understand it
completely. I also understand that execution of this Consent and Release is a condition
of employment with the Company and my refusal to sign will result in withdrawal of any
offer of employment I may receive. I am signing this form voluntarily and have not been
coerced nor placed under duress by any person.
Applicant
Witness 1
Date:__________________________________
Print Name: _________________________
Applicant Name: _________________________
Signature: ___________________________
Applicant Signature:_______________________
Witness 2
Social Security No. _______________________
Print Name:__________________________
Signature:___________________________
NOTICE TO APPLICANTS
NOTICE TO APPLICANTS
You should include this Notice in any application for employment. This Notice should also be posted in an
appropriate and conspicuous location on your premises and made available for inspection by the general
public during regular business hours in your personnel office. This form should be completed at the same
time of the employment application.
D.A.B. CONSTRUCTORS, INC. (The Company) has established and maintains a Drug-Free
Workplace Program. This Drug-Free Workplace Program is in conformity with chapter
440.102.Fla.Stat., its implementing regulations, and Federal law.
As part of this Program, offers of employment are expressly conditioned upon passing a
drug test. In addition, employees of the Company may be subject to drug testing under those
conditions outlined in the Company’s Drug and Alcohol Policy Statement.
For persons receiving a conditional offer of employment, failure of a drug test or refusal to
submit to drug testing when required by the Company shall terminate any job offer. For
employees, failing a drug test or refusing to submit to a drug test will result in action against an
employee up to and including termination of employment.
Persons receiving a conditional offer of employment will have an opportunity to
confidentially report to the Medical Review Officer (MRO) the use of prescription or nonprescription medications both before and or after being tested. Additionally, job applicants shall
receive a list of common medications which may alter or affect a drug test. Job applicants will
also be given the names, addresses, and telephone numbers of local alcohol and drug
rehabilitation programs.
Any person receiving a conditional offer of employment who fails a drug test may
challenge or explain the result within five (5) working days after written notification of the test
result. A job applicant will also have an opportunity to request a retest at the job applicant’s
expense. If a job applicant’s explanation or challenge is unsatisfactory, the job applicant may
contest the drug test results pursuant to rules adopted by the Department of Labor and
Employment Security or the Agency for Health Care Administration.
The job applicant also has the responsibility to notify the laboratory or clinic conducting
the drug test of any administrative or civil action brought involving the drug test conducted by that
laboratory or clinic.
The job applicant also has a right to consult the testing laboratory or clinic for technical
information regarding prescription and non-prescription medication. In addition, each job
applicant will be given a list of the substances to be tested prior to administration of the drug
tests. All test results will remain confidential except as allowed by law. The Company will provide
all job applicants with a copy of the company’s Drug and Alcohol Abuse Policy Statement prior to
administration of a drug test.
Nothing is this Notice will affect these rights provided in any collective bargaining agreement
between the Company and its employees. Refusal to complete or sign this document will result
in a withdrawal of any offer of employment.
(NAME OF COMPANY) D.A.B. CONSTRUCTORS, INC.
Applicant: ____________________________________
Date:_____________________ Witness: _____________________________________
D.A.B.
Constructors, Inc.
P.O. Box 1589 * Inglis, Florida 34449
(352) 447-5488 * Fax (352) 447-4133
MOTOR VEHICLE REPORT RELEASE
June 13, 2003
As part of the employment process, I understand that D.A.B. Constructors, Inc. will
obtain a copy of my motor vehicle report.
I give permission for D.A.B. Constructors, Inc. and its insurance agents to obtain this
report.
________________________________
Signature
________________
Date
________________________________
Print Name
List any and all traffic accidents that you have been involved in over the past five years.
5
DAB Constructor’s Inc.
PRE-HIRING MEDICAL QUESTIONAIRE
This questionnaire is used solely for the purpose of providing the employer with information for the Special Disability Trust Fund
(Second Injury Fund) in appropriate cases. The Questionnaire is not being used as the basis for deciding whether to employ you.
Name_____________________________________________________________Height:_______ Weight: _________
Social Security No: __________________________________________________
INSTRUCTIONS: Check YES or NO to the following questions in the appropriate boxes below. If your answer is YES please list
the approximate date of injury or treatment and give details (doctor, hospital, city, state, etc.) in the space provided for details. Be sure
to specify which numbered questions you are providing details for in the right-hand column.
DO YOU OR HAVE YOU EVER HAD:
1.
A back injury?
2.
A herniated intervertebral disc in your back?
3.
Back surgery for removal of disc?
4.
A neck injury?
5.
A herniated disk in your neck?
6.
Neck surgery for removal of disk?
7.
A right or left knee injury? Please specify.
8.
A surgery on right or left knee? Please specify.
9.
A right or left shoulder injury? Please specify.
10. A surgery on right or left shoulder? Please specify.
11. A right or left elbow injury?
12. A surgery on right or left elbow?
13. Arthritis or Rheumatism?
14. Amputation of foot, leg, arm, hand, finger or toe?
15. Epilepsy?
16. Diabetes?
17. Cardiac disease (heart trouble)?
18. Marie-Strumpell disease (Ankylosing Spondylitis)?
NO  _________________________
YES NO  _________________________
YES NO  _________________________
YES NO  _________________________
YES NO  _________________________
YES NO  _________________________
YES NO  _________________________
YES NO  _________________________
YES NO  _________________________
YES NO  _________________________
YES NO  _________________________
YES NO  _________________________
YES NO  _________________________
YES NO  _________________________
YES NO  _________________________
YES NO  _________________________
YES NO  _________________________
YES NO  _________________________
YES NO  _________________________
YES
19. Total loss of sight of one or both eyes or a partial
loss of corrected vision of more than 75% bilaterally?
20. Residual disability from Poliomyelities?
21. Cerebral Palsy?
NO  _________________________
YES NO  _________________________
YES
22. Multiple Sclerosis?
23. Parkinson’s Disease?
24. A Vascular Disorder?
NO  _________________________
YES NO  _________________________
YES NO  _________________________
YES NO  _________________________
YES
25. Psychoneurotic disability following treatment in a
recognized medical or mental institution for a period in excess of 6 months?
NO  _________________________
Chronic Osteomyelitis?
YES NO  _________________________
Ankylosis of a major weight-bearing joint?
YES NO  _________________________
Hyperinsulinism?
YES NO  _________________________
Muscular Dystrophy?
YES NO  _________________________
Thrombophlebitis?
YES NO  _________________________
Total Deafness?
YES NO  _________________________
Have you ever been classified as Mentally Retarded? YES NO  _________________________
Any permanent physical condition which
YES NO  _________________________
26. Hemophilia?
27.
28.
29.
30.
31.
32.
33.
34.
YES
constitutes a 20% impairment of a member of the body as a whole?
35. Are you now or have you ever been obese?
(30% or more over normal body weight)?
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
NO  _________________________
NO  _________________________
High blood pressure?
YES NO  _________________________
Varicose veins or leg ulcer?
YES NO  _________________________
Tuberculosis?
YES NO  _________________________
Allergies or Asthma?
YES NO  _________________________
Skin trouble?
YES NO  _________________________
Reaction to serum or drug?
YES NO  _________________________
Kidney or Bladder trouble?
YES NO  _________________________
Ulcers?
YES NO  _________________________
Head injury?
YES NO  _________________________
Cancer?
YES NO  _________________________
Rupture (Hernia) (Which side?) Surgery performed? YES NO  _________________________
Any injury, operation or disability not covered by above questions?
YES NO  _________________
Is there any question you do not understand? Please specify… YES NO  _____________________
36. Rheumatic Fever?
37.
YES
YES
All statements and information given in this application are true, to the best of my knowledge and belief.
Name of Applicant ____________________________Signature of Applicant_______________________________
Reviewed by _____________________________Title___________________________________________Date__________