Insulation Helper

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Applicant Information

Full Name(Required)

Your Email(Required)

Street Address(Required)

City(Required)

State(Required)

Zip Code

Cell Phone(Required)

Telephone Number

Social Security Number(Required)

Please enter only the last 4 digits of your Social Security number.

Do you have your own transportation and the ability to travel out of town (hours away) on a regular basis as the job requires?(Required)

Yes

How did you learn of our organization?(Required)

Availability

Are you presently employed?(Required)

Yes

May we contact your current employer?(Required)

Yes

If hired, when are you available to start?(Required)

What are your salary requirements?(Required)

Are you at least 18 years old?(Required)

Yes

Are you available to work full-time?(Required)

Yes

High School

Name / Location(Required)

Year completed(Required)

Major Courses(Required)

Diploma / Degree(Required)

College Education

Name / Location(Required)

Years completed(Required)

Major Courses(Required)

Diploma / Degree(Required)

Business or Trade School

Name / Location(Required)

Time Attended(Required)

Major Courses(Required)

Diploma / Degree(Required)

Military Service

Did you serve in the armed forces?(Required)

Yes

If so, briefly describe the skills you acquired:

Employment History

List your three most recent jobs held.

Employer 1

Employer(Required)

Address / City(Required)

Name of Supervisor(Required)

Employed from/to (month/year)(Required)

Type of work performed(Required)

Reason for leaving(Required)

Employer 2

Employer(Required)

Address / City(Required)

Name of Supervisor(Required)

Employed from/to (month/year)(Required)

Type of work performed(Required)

Reason for leaving(Required)

Employer 3

Employer(Required)

Address / City(Required)

Name of Supervisor(Required)

Employed from/to (month/year)(Required)

Type of work performed(Required)

Reason for leaving(Required)

May we contact the employers listed?(Required)

Yes

If not, please explain:(Required)

Personal Information

Are you legally authorized to work in the U.S.?(Required)

Yes

Have you ever been convicted of a crime or are there any pending charges against you?(Required)

Yes

If so, please explain:

Please list any machines/equipment you are experienced in operating.(Required)

Please list any other skills or training you think we should know about.(Required)

Protected veteran definitions and resources

Veteran of the Vietnam Era: A veteran of the U.S. military, ground, naval, or air service whose service included the period August 5, 1964 through May 7, 1975, who served on active duty for more than 180 days and was discharged or released other than dishonorably, or was discharged or released because of a service-connected disability. This also includes qualifying service in the Republic of Vietnam between February 28, 1961 and May 7, 1975.

Special Disabled Veteran: A veteran discharged or released from active duty because of a service-connected disability, or entitled to qualifying compensation for disabilities administered by the Department of Veterans Affairs.

Disabled Veteran: A veteran entitled to disability compensation under laws administered by the Secretary of Veterans Affairs, or discharged or released from active duty because of a service-connected disability.

Recently Separated Veteran: A veteran within the applicable period beginning on the date of discharge or release from active duty.

Other Protected Veteran: A veteran who served on active duty during a war or in a campaign or expedition for which a campaign badge was authorized.

Armed Forces Service Medal Veteran: A veteran who participated in a U.S. military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

Resources: USERRA information and the U.S. Department of Labor Veterans’ Employment and Training Service.

Veteran Status

Not a Veteran

Protected Veteran

I do not wish to answer

Voluntary. Check all that apply.

How do I know if I have a disability?
You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

Disabilities include, but are not limited to: blindness, deafness, cancer, diabetes, epilepsy, autism, cerebral palsy, HIV/AIDS, schizophrenia, muscular dystrophy, bipolar disorder, major depression, multiple sclerosis (MS), missing limbs or partially missing limbs, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder, impairments requiring the use of a wheelchair, and intellectual disability.

Disability Status(Required)

Yes, I have a disability

No, I do not have a disability

I don’t wish to answer

Voluntary.

Additional Reference

Please provide a reference who is not a relative.

Name(Required)

Occupation(Required)

Address(Required)

Phone Number(Required)

Applicant Certification

I certify that the answers given by me to the foregoing questions and statements are true and correct to the best of my knowledge without consequential omissions of any kind. I agree that the Company shall not be held liable in any respect if my employment is rejected or subsequently terminated because of false statements, answers, or omissions made by me in this application.

I understand that any misleading or incorrect statements may render this application void and, if employed, may lead to employment termination. I understand that a medical examination based on the requirements of the position for which I am being considered may be required, and that drug testing/passing will be required as a condition of employment.

I voluntarily authorize Kirby-Vass Insulation Inc. to perform complete background checks on me, both before and during my employment at any time, and understand that the information obtained may be used in consideration of my employment or continued employment. I also voluntarily and knowingly authorize the companies, schools, or persons named above to give any information requested regarding my former employment, character, and qualifications.

I hereby voluntarily and knowingly fully release and discharge, absolve, indemnify, and hold harmless said companies, schools, or persons from any and all liability for any damages for issuing this information, except for the malicious and willful disclosure of derogatory facts concerning my employment made for the express purpose of preventing me from obtaining employment, which the party disclosing such facts knows to be untrue.

In consideration of my employment, I agree to conform to the rules and regulations of this organization. My employment and compensation can be terminated with or without cause and with or without notice, at any time, at the option of either my employer or myself.

Do you certify that all information given is true and correct to the best of your knowledge?(Required)

Yes

Today's Date(Required)

Accommodation

Do you require reasonable accommodation?

Yes

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples include changing the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

Section 503 of the Rehabilitation Act of 1973, as amended. For more information, visit the U.S. Department of Labor Office of Federal Contract Compliance Programs.

Public burden statement: Under the Paperwork Reduction Act of 1995, no person is required to respond to a collection of information unless it displays a valid OMB control number. This survey should take about five minutes to complete.

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Insulation Helper

Applicant Information

Availability

High School

College Education

Business or Trade School

Military Service

Employment History

Employer 1

Employer 2

Employer 3

Personal Information

Additional Reference

Applicant Certification

Accommodation