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Employment Application

Please fill out the information below as complete as you can.

An Equal Opportunity Employer
Females and Minorities are encouraged to apply.
 

HRI, INC., hereafter known as the Company, does not discriminate in employment on the basis of race, age, color, religion, national origin, sex, disability, or veteran status. No question on this application is intended to secure information to be used for such discrimination.
 

Personal Information
First Name Middle Initial
Last Name Email Address
Social Security Number    
Present Address Info
Address City
State Zip
Home Phone Cell Phone
How long?    
Past Address Info
Address City
State Zip
How long?    
Employment Information
Position Desired CDL Class B and C Drivers Salary Expected
Desired Type Full-time Part-time Temporary If temporary, how long?
What days and hours are you available to work? Date available
Are you over the age of 18? Yes No Are you legally eligible to work in the U.S.? Yes No
If you are not a U.S. citizen, please provide your Form I-551 and state your Alien Registration Number
If you have previously worked for HRI, INC., give dates, location, your name if different from above, and reason for leaving Yes No
Date Left Location
Name if different from above Reason for leaving
Are you related to anyone employed by HRI, INC.? If yes, give name and relationship Yes No
Name Relationship
Have you ever been convicted of a breach of faith offense (including but not limited to killing, larceny, robbery, embezzlement, forgery, shoplifting, perjury, tax evasion, etc.)? Yes No
If yes, explain offense
Are you presently employed? Yes No May we contact your present and past employer(s)? Yes No
Reason for seeking other employment?
Do you have a valid driver's license? Yes No If so, driver's license number
Issuing State Expiration date
Education
School Name and Location Years* Attended Did You Graduate? Specify Degree and Major
High School
Yes No
Trade or Business School
Yes No
College/University
Yes No
College/University
Yes No

* The Age Discrimination In Employment Act of 1967 prohibits discrimination on the basis of age with
respect to individuals who are at least 40 but less than 70 years of age.

List scholarships, academic honors, awards, memberships and elected offices held in extra-curricular school or professional activities. (Exclude those indicating race, religion, age, color, sex, national origin, disability, or veteran status.)
Emergency
In case of emergency notify: Name Relationship
Address
Home Phone Work Phone
It is the policy of this company to request a Pre-employment Physical/Drug Screening of potential new hires/rehires.
I understand this policy and agree to have the requested pre-employment physical/drug test. (initials here)
Will You Abide By The Safety Rules Of This Company? Yes No If Injured, Will You Accept The Medical Facilities Recommended By Your Employer? Yes No
References
  Name Address Occupation Yrs. Known
# 1
# 2
# 3
Employment History

Begin with most recent employment. Include work while in school and periods of unemployment

Company # 1
Company Address
City State
Zip Type of business
Employed (month & year) From To
  Full-Time Part-Time Part-Time hours per week
Salary or wage Monthly Weekly Hourly
Wage/Salary Beginning $ Ending $
Position(s) held If you worked under a different last name, indicate name used
Supervisor's name/position Company phone number
May we contact? Yes No Reason for leaving
Describe your duties. For equipment operators, be specific as to type of equipment experience.
 
Company # 2
Company Address
City State
Zip Type of business
Employed (month & year) From To
  Full-Time Part-Time Part-Time hours per week
Salary or wage Monthly Weekly Hourly
Wage/Salary Beginning $ Ending $
Position(s) held If you worked under a different last name, indicate name used
Supervisor's name/position Company phone number
May we contact? Yes No Reason for leaving
Describe your duties. For equipment operators, be specific as to type of equipment experience.
 
Company # 3
Company Address
City State
Zip Type of business
Employed (month & year) From To
  Full-Time Part-Time Part-Time hours per week
Salary or wage Monthly Weekly Hourly
Wage/Salary Beginning $ Ending $
Position(s) held If you worked under a different last name, indicate name used
Supervisor's name/position Company phone number
May we contact? Yes No Reason for leaving
Describe your duties. For equipment operators, be specific as to type of equipment experience.
 
SUPPLEMENTAL APPLICATION FOR TRUCK DRIVERS
DRIVER LICENSE STATE LICENSE NO. CLASS EXPIRATION DATE
Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No
Has any license, permit or privilege ever been suspended or revoked? Yes No
DRIVING EXPERIENCE
TYPE OF EQUIPMENT OPERATED
(TRI-AXLE DUMP, TANDEM FUEL, TRACTOR, ETC.)
EMPLOYER DATES FROM DATES TO APPROX. NO. OF MILES
SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER
WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM?
ACCIDENT RECORD
DATES NATURE OF ACCIDENT
(HEAD-ON, REAR-END, UPSET, ETC.)
FATALITIES INJURIES
TRAFFIC CONVICTIONS AND FORFEITURES (OTHER THAN PARKING VIOLATIONS)
LOCATION DATE CHARGE PENALTY

"I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND UNDERSTAND THAT, IF EMPLOYED, FALSIFIED STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS FOR DISMISSAL. I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY HAVE, PERSONAL OR OTHERWISE, AND RELEASE ALL PARTIES FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM FURNISHING SAME TO YOU.

I UNDERSTAND AND AGREE THAT, IF HIRED, MY EMPLOYMENT IS FOR NO DEFINITE PERIOD AND MAY, REGARDLESS OF THE DATE OF PAYMENT OF MY WAGES AND SALARY, BE TERMINATED AT ANY TIME WITHOUT ANY PRIOR NOTICE."

Applicant's Certification (Please read carefully before submitting)

Please read the following statements before signing. If you have any questions, please discuss them with a Human Resources representative before signing.

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that falsified statements will be cause for removal from consideration or grounds for immediate dismissal if employment has already commenced.

If hired, I agree to comply with the policies and procedures of the Company. I understand- that employment may be conditioned upon my physical ability to perform the job with reasonable accommodation. I understand that from time to time the Company may require a health evaluation which may include a physical examination by a doctor selected by the Company and periodic drug and/or alcohol tests.

I authorize investigation of all statements and references contained herein, all information concerning my previous employment, any pertinent information, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing this information. Additionally, I authorize the Company to supply my employment record, in whole or in part, and in confidence, to any prospective employer, government agency, or other party, with a legal and proper interest.

As outlined in Section 606 of the Fair Credit Reporting Act, the Company may make an investigative consumer report, including information as to my character, general reputation and personal characteristics. Within a reasonable time of the receipt of this notification, I may request in writing a disclosure of the nature and scope of any such investigation.

All employment offers are made contingent on the above.

I understand and agree that if hired, my employment is for no definite period and may, regardless of the date of payment of my wages or salary, be terminated at any time without prior notice.

All HRI, INC. Applicants

Submission of this information is voluntary and refusal to provide it will not affect consideration for employment.

HRI, INC. is a federal government contractor subject to Section 503 of the Rehabilitation Act of 1973 and Section 402 of the Vietnam Era Veterans Readjustment Assistance Act of 1974, which requires government contractors to take affirmative action to employ and advance qualified disabled individuals, qualified disabled veterans and veterans of the Vietnam era.

If you have such a disability or if you are a disabled veteran or Vietnam era veteran covered by this program and would like to be considered under the Affirmative Action Program, please complete the "Applicant Disclosure Statement" in addition to the "Applicant Data" section.

Your information will be kept confidential and used only for the purposes of the Acts and the regulations issued under them, except (A) supervisors and managers may be informed regarding restrictions on your work or duties and necessary accommodations, (B) appropriate personnel may be informed, if the condition might require emergency treatment, and (C) government officials investigating compliance with the Acts will be informed.

A disabled person is one who (A) has a physical or mental impairment substantially limiting at least one of the major life activities, (B) has a record of such physical or mental impairment, or (C) is regarded as having such physical or mental impairment.

For purposes of this definition, "substantially limiting" occurs when an individual is likely to experience difficulty in securing, retaining, or advancing in employment.

A major life activity includes functions such as caring for one's self, performing manual tasks, socializing, walking, communicating, seeing, breathing, learning and working. Primary attention is given to those life activities that may affect employment.

A disabled veteran is a person entitled to disability compensation under laws administered by the Veterans Administration for disability rated as 30% or more, or a person whose discharge or release from active duty was for a disability incurred or aggravated in the line of duty.

"Veteran of the Vietnam era" means a person who served on active duty for a period of more than 180 days, any part of which occurred between August 5, 1964 and May 7, 1975, and was discharged or released for a service-connected disability or discharged or released with other than a dishonorable discharge.

APPLICANT DATA
Please complete all areas*
Date of Application    
Race White
Black
Hispanic
Asian American
American Indian
Referral Source Advertisement
Customer referral
Employee (current or former)
Employment agency
Public agency (local, state, federal)
Walk-in
Other
Disability Yes No Sex Male Female
Veteran Status Veteran
Disabled Veteran
Vietnam era Veteran
Disabled Vietnam era Veteran
Other protected Veteran
No Veteran Status
Information Not Disclosed
Position Type Full-time Part-time
*The information requested is not utilized in the employmentlinterview process and will not affect any employment decision. It is Information required to be maintained by various Federal Regulations. Providing this Information is voluntary, confidential and will not be used adversely against any applicant.
APPLICANT DISCLOSURE STATEMENT
If you are disabled, a Vietnam era veteran, or a disabled veteran,and you desire to seek assistance in employment placement, please complete this disclosure and sign below. If you are not disabled, a Vietnam era veteran or a disabled veteran or you do not choose to reveal this information, you may omit completion of this disclosure and sigri below.
I am disabled or
I am a disabled veteran or
I am a Vietnam era veteran
and would like assistance in appropriate job placement.
SS# Address
Telephone Number    
Application Submission
I certify that the above statements are correct, and if employed, understand that any false information in this application, or accompanying documents, will be sufficient grounds for termination. I further agree that all policies, procedures, and regulations authorized by the company shall constitute a part of my employment.

I understand if offered employment, it is contingent on the outcome of the background investigations as it relates to my suitability for the employment I seek and the outcome of my drug test.

I further authorize HRI, INC. to check all information contained on the application and applicant materials. I hereby and forever release from any liability former employers and others who provide reference information and assessment of my work history. I further authorize education institutions and schools to provide my education credit if asked by HRI, INC.

Entering your initials in the box provided and pressing submit represents your electronic signature to this specific application.
Initials