Application

McCormick Asphalt Paving  & Excavating, Inc.
A DBE Certified Contractor

Date            

                        An Equal Opportunity Employer
  Must be completed entirely to receive consideration for hire.

                        
 Last Name                      First Name                    Middle Name

      
 Address                     City                 County         State  Zip Code 

                                     
 Home Phone                        Message Phone                   S. S. N.

Date of Birth 

List position you are applying for: 

List skills : 


Date available:  Lowest salary you will accept: 
Have you worked here before?          When: 
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Driving Record: 
Do you have a current and valid driver's license?  yes   No 
State  License Number  Expires on 
Do you have a Commercial Drivers license?  which class? A   B 
List any endorsements on your CDL  
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Military History Record: 
Service Branch  Date Entered  Discharged 
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Education Record: 
Name Grade School & address 
Name High School & address 
Did you graduate?       G.E.D.?       What year? 
Last grade completed    Technical or Trade School 
Subject   Did you graduate?   Year 
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REFERENCES: 
List three persons who are NOT related to you and have a definite 
knowledge of your qualifications  and fitness for the job you are
applying for.

 Name                      Address                   Phone Number

WORK HISTORY: 
List below your prior employers, for a period of 5 years,including any periods 
of unemployment or school.  Beginning with the most recent:

Employer1:  Address1: 
Ph1:  From1:  To1:  Rate of Pay1: 
Reason for leaving1: 
Supervisor1:   Describe Duties1: 
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Employer2:  Address2: 
Ph:  From2:  To2:  Rate of Pay2: 
Reason for leaving2: 
Supervisor2:   Describe Duties2: 
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Employer3:  Address3: 
Ph:  From3:  To3:  Rate of Pay3: 
Reason for leaving: 
Supervisor3:   Describe Duties3: 
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Employer4:  Address4: 
Ph4:  From4:  To4:  Rate of Pay4: 
Reason for leaving4: 
Supervisor4:   Describe Duties4: 
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May we contact your former employers?  Do you have any physical condition 
which could limit your ability to perform the particular type work that is done 
at McCormick Asphalt Paving and Excavating, Inc.?  If yes, explain: 
 Have you been convicted of a felony 
in the past 7 years?  If yes , explain: 


It is understood and agreed that any misrepresentation by me in this application
will be sufficient cause for cancellation of this action. The facts set forth in
my application for employment are true and complete. I understand that if I am 
employed, false statements on this application shall be considered sufficient 
cause for dismissal . You are hereby authorized to make any investigation of my
employment history. As a condition of employment I agree to arbitrate any & all 
disputes arising in connection with the employment relationship ,including , but
not limited to race, age, sex, and handicap discrimination claims. 

SIGNATURE _________________________________        DATE ________________________