Full Name (required)

Your Email (required)

Subject

Street Address

City

State

Zip Code

Telephone Number

Cell Phone

Social Security

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

How did you learn of our organization?

EDUCATION:

High School:
Name/Location

Year completed
789101112

Major Courses

Diploma/Degree

College Education:
Name/Location

Year completed
1234more

Major Courses

Diploma/Degree

Business or Trade School:
Name/Location

Time Attended

Major Courses

Diploma/Degree

Did you serve in the armed forces?
yesno

If so, briefly describe the skills you acquired:

Are you presently employed?
yesno

May we contact your employer?
yesno
If hired, when are you available to start?

What are your salary requirements?

Are you atleast 18 years old?
yesno
Are you available to work full-time?
yesno
EMPLOYMENT HISTORY: (list your 3 most recent jobs held)
Employer:

Address/City:

Name of Supervisor:

Employed from/to (month/yr):

Type of work performed:

Present or last salary:

Reason for leaving:

Employer:

Address/City:

Name of Supervisor:

Employed from/to (month/yr):

Type of work performed:

Present or last salary:

Reason for leaving:

Employer:

Address/City:

Name of Supervisor:

Employed from/to (month/yr):

Type of work performed:

Present or last salary:

Reason for leaving:

May we contact the employers listed?
yesno
If not, please explain...

PERSONAL INFORMATION:
Are you legally authorized to work in the U.S.?
yesno
Have you ever been convicted of a crime or are there any pending charges against you?
yesno
If so, please explain...

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

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

ADDITIONAL REFERENCE (not a relative):
Name:

Occupation:

Address:

Phone Number:

Do you certify that all information given is true and correct to the best of your knowledge?
yesno
Today's Date

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
EQUAL EMPLOYMENT OPPORTUNITY VOLUNTARY SELF-IDENTIFICATION APPLICANT SURVEY:
Our company is an equal opportunity employer and does not discriminate against any employee or
applicant for employment on the basis of race, color, religion, sex, national origin, age, disability, or
any other basis protected by law. No question on this form is intended to secure information to be
used for such discrimination.
The company is required by federal regulation to report information as requested below. Your
contribution of this information is completely voluntary. The information you provide is strictly
confidential and will be maintained separate from your personnel file
Name:

Position applying for:

Date:

Please Check One:
MaleFemale
Appropriate Race/Ethnic Group:
WhiteHispanic or LatinoNative Hawaiin/ Pacific IslanderBlack/ African AmericanAmerican Indian/Alaskan NativeAsianTwo or more racesOther
Please check all that apply:
Not a VeteranProtected VeteranI do not wish to answer
PROTECTED VETERAN DEFINITIONS:
-Veteran of the Vietnam Era:
Veteran of the U.S. military, ground naval, or air service, and part of whose service was during the period August 5, 1964 through May7, 1975, who:
1. served on active duty for a period of more than 180 days and was discharged or released with other than a dishonorable discharge, or
2. was discharged or released from active duty because of a service connected disability. “Vietnam era veteran” also includes any veteran of the U.S. military,
ground, naval, or air service who served in the Republic of Vietnam between February 28, 1961 and May 7, 1975.
-Special Disabled Veteran:
Veteran who served on active duty in the U.S. military ground, naval, or air service, and:
1. who was discharged or released from active duty because of a serviceconnected disability, or
2. who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) for certain disabilities under laws
administered by the Department of Veterans Affairs (i.e., disabilities rated at 30 percent or more, or at 10 or 20 percent if the veteran has been determined to
have a serious employment handicap).
-Disabled Veteran:
Veteran who served on active duty in the U.S. military ground, naval, or air service, and:
1. is entitled to disability compensation (or who but for the receipt of military retired pay would be entitled to disability compensation) under laws administered by
the Secretary of Veterans Affairs, or
2. was discharged or released from active duty because of a service-connected disability.
-Recently Separated Veteran:
With respect to federal contracts and subcontracts entered into before December 1, 2003:
Any veteran who served on active duty in the U.S. military ground, naval, or air service during the one-year period beginning on the date of such veteran’s discharge or
release from active duty.
With respect to federal contracts and subcontracts entered into on or after December 1, 2003:
Any veteran who served on active duty during the three-year period beginning on the date of such veteran’s discharge or release from active duty.
-Other Protected Veteran:
Any other veteran who served on active duty in the U.S. military ground, naval, or air service during a war or in a campaign or expedition for which a campaign badge
has been authorized, other than a special disabled veteran, veteran of the Vietnam era, or recently separated veteran.
-Armed Forces Service Medal* Veteran:
Veteran who, while serving on active duty in the U.S. military ground, naval, or air service, participated in a United States military operation for which an Armed
Forces service medal was awarded pursuant to Executive Order 12985 (61 Fed. Reg. 1209).
* To determine eligibility for Veterans Preference e please click on the following link: http://www.dol.gov/elaws/vets/vetpref/choice.html
Additional website links:
USERRA Notice: http://www.dol.gov/vets/programs/userra/USERRA_Poster.pdf United States
Department of Labor: http://www.dol.gov/vets/
Please check one:
Yes, I have a disabilityNo, I do not have a disabilityI don't wish to answer
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, Intellectual disability (previously called mental retardation)
Do you require reasonable accommodation?
YesNo
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 of reasonable accommodation include making a change to 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 about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.
PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.