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Application

May 12, 2015 @ 1:58 pm
Adam Heath

APPLICATION FOR EMPLOYMENT

Canby Excavating, Inc.
P.O. Box 848
Canby, OR 97013

25361 S. Hwy. 99E, Aurora, OR 97002
Phone: 503-266-2792
Fax: 503-263-0109

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any
basis including race, color, age, sex, religion, disability or national origin. Consistent with the Americans
with Disabilities Act, applicants may request accommodations needed to participate in the application process.

PERSONAL INFORMATION

Date:
Social Security Number:

Last Name :
First Name :
Middle Name :

Current Addresss:
Street :
City:
State :
Zip :

Mailing Address (if different):
Street :
City:
State :
Zip :

Phone Number:
Referred by:
Are you 18 years of age or older?
Yes
No

EMPLOYMENT DESIRED

Position:
Date you can start:
Salary desired:
Are you employed now?
Yes
No
If so, may of your we inquire employer?
Yes
No
Ever applied to this company before?
Yes
No
When?

EDUCATION

  Name and location Circle last year completed Did you graduate? Subjects studied/degrees received
Grammar School
High School
College
Trade, Business or Correspondence

GENERAL

Subjects of special study or skills useful to this Company (typing, driver’s license, etc.) :

FORMER EMPLOYERS

List below your last four employers, starting with the last one first.

Date
Month/Year
Name and address of employer Salary (upon leaving) Position Reason for leaving
From
To
From
To
From
To
From
To

REFERENCES

List below three persons not related to you, whom you have known at least one year.

Name Address Position Years Acquainted
1
2
3

If you are to be hired by the company, you will be required to attest to your identity and employment eligibility, and to present
documents confirming your identity and employment eligibility. You cannot be hired if you cannot comply with these requirements.

AUTHORIZATION

I certify that the facts contained in this application (and accompanying resume, if any) are true and complete to the best of my
knowledge. I understand that any false statement, omission, or misrepresentation on this application is sufficient cause for
refusal to hire, or dismissal if I have been employed, no matter when discovered by the Company.

I understand that any employment is conditioned on a background check. I authorize the Company to thoroughly investigate
all statements contained in my application or resume, and I authorize my former employers and references to disclose information
regarding my former employment, character and general reputation to the Company, without giving me prior notice of
such disclosure. In addition, I release the Company, any former employers and all references listed above from any and all
claims, demands or liabilities arising out of or related to such investigation or disclosure.

I understand and agree that nothing contained in this application, or conveyed during any interview, is intended to create an
employment contract. I further understand and agree that if I am hired, my employment will be “at will” and without fixed term,
and may be terminated at any time, with or without cause and without prior notice, at the option of either myself or the
Company. No promises regarding employment have been made to me, and I understand that no such promise or guarantee
is binding upon the Company unless made in writing.

If I am offered employment I agree to submit to a medical examination and drug test before starting work. If employed, I also
agree to submit to a medical examination or drug test at any time deemed appropriate by the Company and as permitted by law.
I consent to such examinations and tests, and I request that the examining doctor disclose to the Company the results of the
examination, which results shall remain confidential and segregated from my personnel file. I understand that my employment or
continued employment, to the extent permitted by law, is contingent upon satisfactory medical examinations and drug test, and
if I am hired a condition of my employment will be that I abide by the Company’s Drug and Alcohol Policy.

I understand that filling out this form does not indicate there is a position open and does not obligate the Company to hire.
If hired, I agree to abide by all Company work rules, policies and procedures. The Company retains the right to revise its
policies or procedures, in whole or in part, at any time.

Date:
Signature: