Position Desired

Date

Wage Desired

Were you referred to Pink by a Pink Employee?

Other referral source?

Personal history

Name as shown on your social security card



Telephone Number

Cell Phone Number

Present Address




Previous Address




Email Address

Give particulars of your work history, if any, for at least the past 5 years, regardless of type of work.

Employer #1
Present or most recent employer Month and Year Positions held and duties performed
Employer #2
Present or most recent employer Month and Year Positions held and duties performed
Employer #3
Present or most recent employer Month and Year Positions held and duties performed
Employer #4
Present or most recent employer Month and Year Positions held and duties performed

Education and Training

Name and Location
Graduate
Yes or No
Major Subject
& Hrs Completed
Minor Subject
& Hrs Completed
Total
Hours
High School
College(s)
Trade or
Technical Schools

List the skills that you are crossed trained in or additional special skills you may have relating to construction work that you can perform.

Experience and Qualifications - Heavy Equipment

Show Equipment You Can Operate
Check Years of Experience
Equipment Check Years of Experience

Bobcat
 Yes Excavator  Yes
Track Loader
 Yes Motor Grader
 Yes
Dozer  Yes Other  Yes

If mechanic, types of equipment repaired:

Type and size of equipment operated (I.E. cat 950, D4, 330):

Type of work (i.e. paving, sewer, dirt):

Experience and Qualifications for Drivings Positions

State
License No.
C.D.L. Type
Expiration Date

If the answer is yes, provide details:

Driving Experience

Class of Equipment
Type and Equipment and Size
Date
Approx No. of Miles or Length of Time
From To
Tractor/Lowboy
Tandem Axle Dump Truck
Tractor and Belly Dump
Tractor and End Dump

Accident Record for Past 3 Years

Your motor vehicle record will be checked if you are hired.

Date Nature of Accident
(Head-on, Rear-end, Upset, etc.)
Fatalities

Injuries
Last Accident
Next Previous
Next Previous

Traffic Convictions and Forfeitures for the Past 3 Years or Felony Criminal Convictions Within the Last 5-10 years

Location Date Charge Penalty

Certification

Read the following carefully:

I certify that the information provided by me on this application is correct. I understand that the furnishing of incomplete information as well as any misleading or incorrect information on this application or its attachments will be just cause for rejection of the application or termination should I become employed at Pink Grading, Inc. Also, any positive drug screening results may be cause for subsequent rejection.

I hereby give permission to the persons and companies listed on this application and its attachments to provide any pertinent information to Pink Grading, Inc, or its duly authorized representative, except where otherwise indicated. I release said parties form all liability for any damages resulting from issuance of such information.

I authorize the release of personal information to Pink Grading for the purpose of verifying my motor vehicle record.

I understand that, if employed, my employment is for no fixed term. My employment may be discontinued, with or without notice and with or without cause, by me or Pink Grading at any time. I understand that no employees, or officer or agent of the Company may bind it to anything contrary to the above by oral or written statements, including handbooks, benefit booklets, or other forms of communication.

As a condition of employment, I hereby voluntarily give my consent to Pink Grading and its designated agents to do urinalysis and/or blood testing for alcohol and/or controlled substances. Such testing will occur as a precondition of my being employed, or any time during my employment at Pink Grading either at random, after an accident in which I am involved or when there is reasonable cause to believe that violations of the Company's drug abuse policy exists. I understand that my refusal to submit to such testing will result in my termination

I represent that I am eighteen (18) years of age or older.

THIS APPLICATION IS NULL AND VOID IF NOT SIGNED AND DATED

Signature of Applicant

Date

Pink Grading Inc is an Equal Employment Opportunity Affirmative Action Employer and is morally and legally committed to non-discrimination in employment. No information requested herein shall be used to effect any unlawful preference, limitation, specification, or discrimination because of race, color, religion, creed, national origin, gender, marital status, age, handicap, disability, citizenship, or Veteran Status.

Voluntary Self-Identification Information

Completion of this information is voluntary and is not a requirement of employment. This information will in no way affect the decision regarding your application for employment. This information will be kept confidential. We hope that you will complete this form to assist us in recording information for statistical reports that we are obliged to file periodically with various government agencies.

Name

Date

Position Applied For

Applicants Identifying Their Sex and Race

Ethnicity

Race

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