EMPLOYMENT

You are welcome to fill out an employment application.

Corporate & Maintenance Office: 11061 Walden Ave., Alden, NY 14004, Attn: Tom

Email it to our main office to: tom@highwayrehab.com.

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EMPLOYMENT APPLICATION

You can also fill out the form below.

Personal Information

(Required)

Last Name First Name Middle Name

Today's Date

MM slash DD slash YYYY

Street Address City State Zip Code

Home Phone(Required)

Work Phone

Mobile(Required)

Email(Required)

Are you a United States Citizen or legally eligible to work in the U.S.?

Yes

(if hired, you will be required to provide documentation that you are eligible to work in the US.)

Are you 18 or over?

Yes

Title of Position Applying For

Date Available to Work

MM slash DD slash YYYY

Have you been previously interviewed or employed by Highway Rehab. Corp.?

Yes

If Yes, list date(s) and job title(s):

Date

MM slash DD slash YYYY

Job Title

Do you have any relatives currently working for Highway Rehab. Corp.?

Yes

If Yes, list names and relationship to you:

Name

Relationship

Are you employed now?

Yes

If so, may we contact your present employer?

Yes

Do you hold a valid driver’s license?

Yes

Type

Driver’s License Number:

State Issued:

Endorsement(s): Check all that apply

Please provide the following information for your previous three employers, beginning with the most recent: (Please attach an additional page, if necessary; do not use “see attached resume.”)

Employer

Date Employed From

MM slash DD slash YYYY

Date Employed To

MM slash DD slash YYYY

Job Title

Address

Telephone

Weekly Pay Start

Weekly Pay Finish

Job Duties:

Reason for Leaving:

Employer

Date Employed From

MM slash DD slash YYYY

Date Employed To

MM slash DD slash YYYY

Job Title

Address

Telephone

Weekly Pay Start

Weekly Pay Finish

Job Duties:

Reason for Leaving:

Employer

Date Employed From

MM slash DD slash YYYY

Date Employed To

MM slash DD slash YYYY

Job Title

Address

Telephone

Weekly Pay Start

Weekly Pay Finish

Job Duties:

Reason for Leaving:

Describe your qualifications for the type of employment you are seeking: (Include skills, special training, etc.)

Have you completed the OSHA 10-hour construction training?

Please list any special awards, honors, scholarships, or offices held.

References

Please list names of supervisors, managers, or others who can comment directly on your abilities:

Name

Address

Phone

Relationship/Occupation

Years Known

Name

Address

Phone

Relationship/Occupation

Years Known

Name

Address

Phone

Relationship/Occupation

Years Known

It is the policy of the Highway Rehab. Corp. Personnel Office to provide accommodations in testing to individuals with disabilities and religious observers, and to provide for and promote equal opportunity in employment, compensation and other terms of employment without regard to age, race, color, gender, creed, religion, national origin, physical or mental disability, marital status, veteran status, disabled veteran status or status as a member of any other protected group or activity.

(Required)

I certify that the facts set forth in this application for employment are true and complete to the best of my knowledge. I understand that if employed, false statements on this application shall be considered sufficient cause of dismissal. You are hereby authorized to make investigation of my personal references.

Signature of Applicant(Required)

Date(Required)

MM slash DD slash YYYY