County. Email Address ... This job may require overnight travel, overtime, and storm response work after hours and on we
EMPLOYMENT APPLICATION (FIELD USE ONLY) Hire Date Wage Rate Job Class EEO Class Crew Leader GF Supv Veteran Vet Svc Dates
(OFFICE USE ONLY)
_____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ __________to_________
Emp# _________________ W-4 _________________ R/S _________________ BD _________________ DL _________________ State _________________ Class _________________ Exp _________________ PSD Code________________
____ Penn Line Corporation _____ Penn Line Service, Inc. _____ Forest Construction Co. _____ Tri County Electric Co. _____ D.W. Miller, Inc.
NOTICE TO APPLICANTS We will make reasonable accommodation for qualified individuals with disabilities upon request, including completing this application. Please notify the Human Resource Department at 724/887-9110 x151 of the accommodation requested. All New Hires and Rehires will be required to furnish ONE (1) FORM OF IDENTIFICATION AND ONE (1) FORM OF DOCUMENTATION THAT ESTABLISHES EMPLOYMENT ELIGIBILITY after valid job offer is made. Any offer of employment by the Company may be contingent upon results of background screening and/or on-boarding processes.
We are an equal opportunity employer and will not discriminate or tolerate discrimination in hiring or employment on the basis of race, religion, age, color, sex, sexual orientation, gender identity, national origin, ancestry, handicap or disability, marital status, veteran status or status within any other protected group or against any employee or applicant in any manner prohibited by law. EOE/AA/M/D/F/H/V PERSONAL DATA (Please list all prior addresses for the last three years on separate sheet and attach to application) Name: _________________________________________________ Social Security No. ________-______-__________ Last
First
Middle Initial
Address: _____________________________________________________________________________________________ Street
Apt. No.
_____________________________________________________________________________________________ City
State
Zip Code
_____________________________________________________________________________________________ County
Email Address
_____________________________________________________________________________________________ Home Telephone
Mobile
Applicants must be 18 years of age to Apply. Are you 18 years of age or older? ____ YES ____ NO Have you ever worked for any of the above listed companies before? ____ YES ____ NO (If YES, give date ______________) This job may require overnight travel, overtime, and storm response work after hours and on weekends upon short notice. Can you meet these requirements? ____ YES ____ NO Do you have your own transportation ? ____ YES ____ NO
Are you available for full time work? ____ YES ____ NO
Have you committed a crime and been convicted within the past 7 years? ____ YES ____ NO (Conviction will not necessarily disqualify applicant)
If yes, explain: _________________________________________________________________________________________ List driver license status for the past three years: CURRENT DRIVER LICENSE(S)
STATE
LICENSE NUMBER
TYPE/CLASS
EXPIRATION
EMPLOYMENT DETAILS Position desired: 1. __________________________________ 2. _____________________________________________ Wages expected: $ _______________________ per hour
Date available: ______________________________________
EMPLOYMENT HISTORY Please list your employment history for the last ten (10) years, starting with your most recent employer. If you need additional space or need to clarify gaps in your employment record, please record on a separate sheet and attach to application. FROM
TO
MO-YR.
MO-YR.
COMPANY
YOUR JOB TITLE
ADDRESS
SALARY
SUPERVISOR’S NAME AND TITLE
REASON FOR LEAVING TELEPHONE
MAY WE CONTACT?
DESCRIPTION OF WORK AND RESPONSIBILITIES
FROM
TO
MO-YR.
MO-YR.
COMPANY
YOUR JOB TITLE
ADDRESS
SALARY
SUPERVISOR’S NAME AND TITLE
REASON FOR LEAVING TELEPHONE
MAY WE CONTACT?
DESCRIPTION OF WORK AND RESPONSIBILITIES
FROM
TO
MO-YR.
MO-YR.
COMPANY
YOUR JOB TITLE
ADDRESS
SALARY
SUPERVISOR’S NAME AND TITLE
REASON FOR LEAVING TELEPHONE
MAY WE CONTACT?
DESCRIPTION OF WORK AND RESPONSIBILITIES
EDUCATION AND TRAINING SCHOOL
NAME & LOCATION
HOW MANY YEARS?
DID YOU COMPLETE?
MAJOR OR TYPE OF COURSE
HIGH COLLEGE VOCATIONAL or APPRENTICESHIP OTHER List any skills or other related training which might be beneficial on the job for which you are applying: __________________ ______________________________________________________________________________________________________
List machines and equipment you can operate and years experience on each: ________________________________________ ______________________________________________________________________________________________________
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MILITARY EXPERIENCE/TRAINING Were you in the armed forces of the United States? _____ YES _____ NO If YES, what branch? _________________ Dates of duty were from ______________ to _______________ Rank at separation? ________________________________ Briefly describe your duties: _____________________________________________________________________________ Have you served active duty where a service medal was awarded? __YES __NO If Yes, what award? _________________ Have you served active duty for which you were awarded a campaign badge? ___YES ___ NO If Yes, for what campaign, war or expedition did you receive the badge?__________________________________________________________________ COMMERCIAL DRIVER APPLICANTS MUST COMPLETE THE FOLLOWING SECTION: Driver Applicants Must be 21 years of Age. Are you 21 years of age or older? _____ YES _____ NO Have you ever been denied a license, permit, or privilege to drive a motor vehicle? _____ YES _____ NO Has your license, permit, or privilege ever been suspended or revoked? _____ YES _____ NO In the past two years, have you tested positive or refused a pre-employment drug or alcohol test that was administered under DOT guidelines and were you subsequently denied a safety-sensitive position (DOT transportation work) that you applied for with this prospective employer? _____ YES _____ NO If the answer to any of the above three questions is YES, please explain below or attach a separate statement: ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Do you currently have a Department of Transportation medical card? _____ YES _____ NO Expiration: _____/_____/_____ Please list any accident record information below for the past three (3) years (attach sheet if more space is needed) NATURE OF ACCIDENT (HEAD-ON, REAR-END, UPSET, ETC.)
DATE
FATALITIES
INJURIES
LAST ACCIDENT NEXT PREVIOUS Please list all traffic convictions and forfeitures below for the past three (3) years (other than parking) LOCATION (CITY, STATE)
DATE
CHARGE
PENALTY
Please enter driver experience in the space provided below CLASS OF EQUIPMENT
TYPE OF EQUIPMENT (Pick-up, van, utility, tank, flat, etc)
DATES From
To
STRAIGHT TRUCK STRAIGHT TRUCK/EQUIPMENT TRAILER
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EMERGENCY CONTACT INFORMATION:
1. NAME: ______________________________________________
2. NAME:____________________________________________________
RELATIONSHIP: ______________________________________
RELATIONSHIP: ____________________________________________
ADDRESS: ___________________________________________
ADDRESS: __________________________________________________
PHONE: _____________________________________________
PHONE: ___________________________________________________
PLEASE READ AND SIGN THE EMPLOYMENT APPLICATION
I hereby authorize and permit Penn Line to obtain information in accordance with regulations applicable to the federal Department of Transportation’s Regulations, the Americans with Disabilities Act, and all other applicable federal, state and local laws: information pertaining to my criminal; civil; motor vehicle; credit; academic history; professional certifications; prior employment records, including performance safety, and driving history; drug and alcohol test records; and military service records, in addition to any and all other information associated with a request, deemed necessary to request, and/or inadvertently provided by a third party to Penn Line Service, Inc. By signing my name below, I certify that all information provided by me, either orally or in writing on this application and any supporting materials, if an offer of employment is made, is true and complete to the best of my knowledge. I understand that any misstated, false or misleading information or omissions made by me during the application process may result in rejection of this application or, in the event of employment, may result in immediate discharge at any time during my employment if discovered at a later date. I understand and agree that if employed, I will be required to abide by all the rules, regulations and policies established by the Company and all applicable governmental agencies, and acknowledge that these rules, regulations and policies are not contractual in nature, and may be amended, changed, interpreted, supplemented or withdrawn at any time, and without prior notice to me. I understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with the Company is of an “at will” nature, which means that I may resign at any time and that the Company may terminate my employment at any time with or without cause and with or without notice. Date: ____/____/____
Signature: ________________________________________________________
Rev. 05/02/2016
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