APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT – PART 1

Certified Utility Services, Inc. (“the Company”) is an equal opportunity employer, dedicated to a policy of nondiscrimination in employment on any basis prohibited by law. The Company considers applicants for all positions without regard to race, color, religion, gender, national origin, age, disability, marital status, veteran status, sexual orientation, gender identity/expression, genetic information or any other legally protected status. The Company will provide equal opportunity in compliance with all applicable laws.
Personal & Position Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone Number*
Please enter a valid phone number.
Work Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Job position applying for:(please include position title and location)
Preferred Hourly Rate/Salary
On what date would you be available to work?

MonthDayYear
Date
Are you available to work holidays?

YesNo
Are you either a U.S. citizen or an alien authorized to work in the United States?

YesNo
If employment is offered, can you produce documentation required by law to establish work authorization and identity?

YesNo
Are you currently on “lay-off” status and subject to recall?

YesNo
Can you work overtime if your job requires it?

YesNo
Can you travel if your job requires it?

YesNo
Do you have reliable transportation to and from work?

YesNo
If your job requires you to use a personal vehicle, would you have one to use?

YesNo
Can you provide a valid driver’s license and proof of insurance if required to drive?

YesNo
How far will you travel to work sites from your home (in miles)?
Have you ever applied to or worked at this Company before?

YesNo
If yes, list dates of employment, location/position and (if applicable) former name:
Do you have any friends or relatives working at the Company?

YesNo
If yes, list name and relationship to you:
Education and Training
High School / Prep School
Address
Years Completed
Diploma/GPA
College/University
Address
Course of Study
Years Completed
Diploma/Degree
Graduate/Trade/Business School
Address
Course of Study
Years Completed
Diploma/Degree
Academic Scholarships/Awards
List any licenses or certifications you have (type, which state(s), date(s), license number(s), expiration)
Has any license or certification you have held been surrendered, suspended or revoked for any reason? If so, please explain:
Military Service (Dates, Branch, Characterization of Discharge)
List any skills or knowledge relevant to the job for which you are applying that you think may be helpful to us in considering your application:
Employment Experience
Have you ever been dismissed, involuntarily terminated or terminated by mutual agreement?

YesNo
Have you ever been asked/forced to resign or given choice to resign rather than termination?

YesNo
If yes to either, please explain:
Starting with your most recent employment, provide your complete employment history for the past 10 years. Include any job-related military service assignments and volunteer activities. Please be aware that your current and previous employers may be contacted. If you provide a resume, you must still provide all this information.
Employer 1
Job Title
Dates Employed
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Duties & Accomplishments
Supervisor (Name & Title)
Reason for Leaving
Employer 2
Job Title
Dates Employed
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Duties & Accomplishments
Supervisor (Name & Title)
Reason for Leaving
Employer 3
Job Title
Dates Employed
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Duties & Accomplishments
Supervisor (Name & Title)
Reason for Leaving
If you have any gaps in employment of 6 months or longer (other than if due to medical reasons), please explain:
Professional References for Employment
Reference 1
Address
Phone
How do they know you?
Reference 2
Address
Phone
How do they know you?
Reference 3
Address
Phone
How do they know you?
NOTICE REGARDING POLYGRAPH TESTS

No applicant or employee shall be required to take a polygraph test or any form of mechanical or electrical lie detector test as a condition of employment or as a condition of continued employment.

NOTICE TO APPLICANTS REGARDING PRE-EMPLOYMENT DRUG AND/OR ALCOHOL TESTING

Any individual applying for employment with Certified Utility Services and/or any of its business affiliates (hereafter “the Company”) may be required to submit to a drug and/or alcohol test as a mandatory part of the employment application process.

This notice serves as a written statement of the Company’s intention to conduct drug and/or alcohol testing as part of the application process. The testing will be conducted in accordance with the procedures required by applicable state and federal regulations. Tested applicants will be given a copy of any positive test result. All test results shall be considered confidential by the Company and shall not be disclosed to the employees of the Company, or any other person, other than to those persons for whom such disclosure is necessary. Positive test results, or a refusal to sign this consent form and participate in pre-employment drug and/or alcohol testing, shall be grounds for denial of employment. Arrangements for testing will be made by a representative of the Company, in consultation with each applicant. Cooperation in scheduling the testing is important for processing an application.

Further, the Company prohibits employees from possessing or being under the influence of alcohol or illegal drugs or from abusing lawful drugs while performing work-related functions. Failure to consent to a properly requested test for drugs or alcohol during the course of employment or failing a drug or alcohol test are grounds for termination of employment.

By signing below, you consent to be drug and/or alcohol tested and acknowledge you have thoroughly read the foregoing notice and policy, and you understand and agree that in order to be considered for employment with the Company, you will comply in full with the Company’s drug and alcohol policies.
Applicant Signature:*
Date:*

MonthDayYear
Date
AT-WILL EMPLOYMENT DISCLAIMER AND APPLICANT’S AGREEMENT AND CERTIFICATION

I certify that the answers given in this application are true to the best of my knowledge, I understand that the use of this application form does not indicate that there are any positions open and does not in any way obligate Certified Utility Services, Inc. or any of its business affiliates (hereafter “the Company”).

If I become employed and in consideration of my employment, I agree to conform to the policies and procedures of the Company, as they may from time to time be implemented or revised, and that my employment and compensation are “at-will” and can be terminated with or without cause at any time for any lawful reason at the option of either the Company or myself. I understand that should I be granted an interview, no representations that may be made at the interview are to be construed as creating any obligation, promise or contract on behalf of the Company that in any way would limit the Company’s right to terminate my employment at will. I understand that no supervisory, management or any other employee at the Company has any authority to make a commitment of guaranteed or continuing employment to me, and no document or publication of the Company or conduct of anyone at the Company should be interpreted to make such a guarantee, unless the President of the Company specifically agrees to such change in writing signed by the President and me.

I understand that false or misleading information given in my application, resume, interview or during the course of my employment may result in withdrawal of a job offer or discipline up to and including termination of employment, whenever the omission or falsehood is discovered.

I understand that acceptance for employment shall depend on satisfactory replies from my references and satisfactory results from any other required background checks or pre-employment tests.

I understand that I may be subject to a drug test and/or a medical examination that I must pass as a condition of employment. I understand that if I am paid a weekly salary rather than an hourly rate, my salary is intended to compensate me for all hours I work, including any hours in excess of 40 hours in a work week.

I understand that I am being considered for employment because of my general skills and knowledge and not because the Company seeks to obtain any confidential or proprietary information belonging to my current or prior employers. I understand I will not need to disclose or rely upon any confidential or proprietary information of my current or prior employers to perform my duties for the Company. By signing below, I further agree that I will not retain any confidential or proprietary information of my current or prior employers, whether in hard copy, electronic or other format, or provide any such information to the Company. I further agree that I will otherwise comply with any obligations I may have to my current or prior employers regarding their proprietary and confidential information, including but not limited to any and all non-disclosure, non-competition or non-solicitation obligations. I further agree that while my current employer continues to employ me, I shall honor my obligation to act only in its best interests.

At the time I complete this application, I agree to inform the Company about whether I am a party to any non-disclosure, non-competition and/or non-solicitation agreement with any current or former employer that remains in effect at the time of my application and to provide a copy of any such agreement to the Company so the Company can determine whether any such agreement may prevent me from being hired. I understand that if I fail to disclose this information and/or provide a copy of any such agreement to the Company, this may result in denial of employment, withdrawal of a job offer or termination of employment (if hired) whenever this omission is discovered.

I have read, understood and agree to the foregoing.
Signature of Applicant:*
Date:*

MonthDayYear
Date
Should be Empty:

APPLICATION FOR EMPLOYMENT – PART 1

Personal & Position Information

Education and Training

Employment Experience

Professional References for Employment