Employment Application

Please fill out the online application below.

Position for which you are applying:*
Check all that you may be interested in:*
- Full Time
- Part Time
- Job Share
Name*
First Middle Last
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Cell Phone
Home Phone
Business Phone
Email
Drivers License #
State
Expiration Date
DD slash MM slash YYYY
- Operators (Private Vehicle)
- CDL (copy needed of license & medical card)
License Class
Endorsement
Are you claiming Veteran’s Preference? (Attach a copy of DD214 and/or service connected disability)
- Yes
- No
Have you ever been convicted of a felony since your 18th birthday? If you answered yes, please complete the following: (Conviction is not an automatic bar to employment. Each case is considered on its individual merits).
- Yes
- No
(Inaccurate information here will result in disqualification.)
If yes, please list nature of offense, name and location of court and date of conviction
Are any of your educational or employment records found under a different last name?
- Yes
- No
If yes, please give the previous last name.
Have you ever been discharged or forced to resign from any position?
- Yes
- No
If yes, please give employer, date and reason.
If hired, are you authorized to work in the United States? For non citizens, a copy of your authorization to work issued by the U.S. Immigration and Naturalization Service must be submitted prior to appointment.
- Yes
- No
Do you now hold or are you a candidate for an elective public office?
- Yes
- No
References
Name
First Last
Phone
Name
First Last
Phone
Name
First Last
Phone
Name
First Last
Phone
Education and Training
Elementary and High School Education
Highest Grade Completed
Did you graduate from High School or obtain a GED?
- Yes
- No
Name of Last School Attended (High School, Junior High or Elementary)
Location
Indicate the number of courses completed in each subject:
Algebra
Biology
Bookkeeping
Calculus
Geometry
Trigonometry
Related Special Training
(Correspodence, Business, Trades, Vocational, Armed Forces Schools, etc.)
Name and Location of First School (If any)
Dates Attended (Mo & Yr)
Courses/Subjects Completed
Credit Hours
Diplomas/Certificates Received
Name and Location of Second School (If any)
Dates Attended (Mo & Yr)
Courses/Subjects Completed
Credit Hours
Diplomas/Certificates Received
Colleges and Universities Attended (Undergraduate and Graduate)
**Must be from a recognized accredited school - Bring original transcript with initial application**
Name and Location of First School (If any)
Dates Attended (Mo & Yr)
Credit Hours
Type of Degree Earned (e.g.BA/BS)
Major
Minor
Name and Location of Second School (If any)
Dates Attended (Mo & Yr)
Credit Hours
Type of Degree Earned (e.g.BA/BS)
Major
Minor
Major Undergraduate College Subjects (Include Credit Hours)
Major Graduate College Subjects (Include Credit Hours)
Related Licenses (provide current original)
List Professional Licenses
Include Issuing Agency, Field/Trade Specialization, License Number, Issue Date, and Expiration Date.
Skills
Also include specific software experience in your job descriptions. Ask about PC skills exams and provide certificates of courses completed.
- Access
- ORACLE
- Approach
- Hansen
- GIS
- Drafting
- Auto Cad
- Excel/Lotus
- Word/WordPerfect
- PowerPoint
- Other Software (Please list below)
- Typing (Please add wpm below)
If you checked Other Software, please list:
If you checked typing, please list WPM.
Languages spoken and written FLUENTLY:
Employment History
May we contact your present employer?*
- Yes
- No
1
Company Name and address (city and state are required)
Starting Date month / day / year
MM slash DD slash YYYY
Ending Date month / day / year
MM slash DD slash YYYY
- Paid Work
- Volunteer
Hours per Week
Name & Title of Immediate Supervisor
Phone
Reason for Leaving
Title of Position Held
Number & Job Title of Employees you Supervised
Describe job responsibilities in order of importance:
2
Employer/Company Name and address (city and state are required)
Starting Date month / day / year
MM slash DD slash YYYY
Ending Date month / day / year
MM slash DD slash YYYY
- Paid Work
- Volunteer
Hours per Week
Name & Title of Immediate Supervisor
Phone
Reason for Leaving
Title of Position Held
Number & Job Title of Employees you Supervised
Describe job responsibilities in order of importance:
3
Employer/Company Name and address (city and state are required)
Starting Date month / day / year
MM slash DD slash YYYY
Ending Date month / day / year
MM slash DD slash YYYY
- Paid Work
- Volunteer
Hours per Week
Name & Title of Immediate Supervisor
Phone
Reason for Leaving
Title of Position Held
Number & Job Title of Employees you Supervised
Describe job responsibilities in order of importance:
Upload files for resume and/or other documentation.
Drop files here or

Max. file size: 40 MB.
Driving Record Release
The employee signing this application authorizes Concrete Placement, Inc. to release information to HUB International Insurance Services, Inc. for the sole purpose of obtaining their driving record. They also authorize HUB International Insurance Services, Inc. to release this information to Concrete Placement, Inc., for the sole purpose of evaluating their insurability as a driver.

This authorization will remain in effect for as long as the person signing below is an employee of Concrete Placement, Inc.
Employee Driver Information
Name
First Middle Last
(Name must be as it appears on your drivers license)
Date of Birth
MM slash DD slash YYYY
Drivers License #
State of Drivers License Issuance:
Conditions of Employment Statement
Under penalties of perjury, I declare that my answers to the questions on this application and any necessary examinations and supplements are true and give Concrete Placement, Inc. the right to investigate all information given and to secure additional appropriate information if necessary. I understand that an investigative report may be made from information obtained through personal interviews with others. I understand that this inquiry may include information as to my personal characteristics, employment verification, credential verification, personal identity verifications, reference checks, criminal records, motor vehicle records, and appropriateness for employment. In accordance with the law and my understanding of this statement, I authorize my current and former employers to give any information regarding my employment, together with all information regarding me, and hereby release from all liability or responsibility all persons, companies, or corporations furnishing such information in good faith. I also authorize the release of my scholastic ratings to the Concrete Placement, Inc by schools and other education institutions that I have attended.

I understand that the completion of this application does not assure me of a position with the Concrete Placement, Inc and does not obligate Concrete Placement, Inc to me in any way. I further understand that any misrepresentation herein may cause my application to be rejected, my name to be removed from the eligible register and/or subject me to dismissal. Candidates selected for hire must pass a physical and drug screen prior to employment. I am aware that the results will be made available to the Human Resources Director or a duly authorized representative. Concrete Placement, Inc. is committed to a drug free work place to protect the safety of workers and the public and will comply with the Federal Drug Free Work Place Act.

I understand that this application, exam documents and attachments become a part of Concrete Placement, Inc. records and will not be returned, reused or copied for me once submitted.
Signature*
By my signature, I certify, authorize and acknowledge the above statements. (Unsigned applications will not be considered)
Date*
MM slash DD slash YYYY
Reminder: With your application, bring original transcripts, training certifications, professional licenses & certifications and other documents as indicated in the application instructions. If a certification or license is renewed after submission of this application, please bring in your current document for us to copy. An expired credential may result in you not being considered for a vacancy.

References

Education and Training

Elementary and High School Education

Related Special Training

Colleges and Universities Attended (Undergraduate and Graduate)

Related Licenses (provide current original)

Skills

Employment History

Driving Record Release

Conditions of Employment Statement