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Personal Information

Name(Required)

First Middle Last

Address(Required)

Street Address City State ZIP Code

Home Phone

Work Phone

Mobile Phone(Required)

Are you a United States Citizen or legally eligible to work in the U. S.?(Required)

(if hired, you will be required to provide documentation that you are eligible to work in the U.S.)

Yes

Are you 18 or over?(Required)

Yes

Title of Position Applying For(Required)

Date Available to Work(Required)

For what type of work are you applying?(Required)

Have you been previously interviewed or employed by the Continuum Restoration?

Yes

If Yes, list date(s) and job title(s):

Date

Job Title

Do you have any relatives currently working for the Continuum Restoration?

Yes

If Yes, list names and relationship to you:

Name

Relationship

Are you employed now?

Yes

If so, may we contact your present employer?

Yes

Education

High School

High School: Name

High School: Location

High School: Years Completed

Please enter a number less than or equal to 8.

High School: Major Area of Study

High School: Degree/Diploma

College

College: Name

College: Location

College: Years Completed

Please enter a number less than or equal to 8.

College: Major Area of Study

College: Degree/Diploma

Graduate School

Graduate School: Name

Graduate School: Location

Graduate School: Years Completed

Please enter a number less than or equal to 8.

Graduate School: Major Area of Study

Graduate School: Degree/Diploma

Technical or Certificate Programs

Name

Location

Years Completed

Please enter a number less than or equal to 8.

Major Area of Study

Degree/Diploma

Employment History

Please provide the following information for your previous three employers, beginning with the most recent.

Employer 1:

Name

Job Title

Start Date

End Date

Address

Street Address City State

Phone

Weekly Pay: Start

Weekly Pay: Finish

Reason For Leaving

Job Duties

Employer 2:

Name

Job Title

Start Date

End Date

Address

Street Address City State

Phone

Weekly Pay: Start

Weekly Pay: Finish

Reason For Leaving

Job Duties

Employer 3:

Name

Job Title

Start Date

End Date

Address

Street Address City State

Phone

Weekly Pay: Start

Weekly Pay: Finish

Reason For Leaving

Job Duties

Qualifications

Describe your qualifications for the type of employment you are seeking: (Please include skills, special training, etc.)

Are you able to perform all of the duties listed for the job being applied for?

Yes

Do you have any special skills related to the job you are applying for?

Yes

Explain

Please list any special awards, honors, scholarships, or offices held.

References

Please list names of supervisors, managers, or others who can comment directly on your abilities:

Reference 1

Name

Address

Street Address City State ZIP Code

Phone

Relationship / Occupation

Years Known

Please enter a number less than or equal to 99.

Reference 2

Name

Address

Street Address City State ZIP Code

Phone

Relationship / Occupation

Years Known

Please enter a number less than or equal to 99.

Reference 3

Name

Address

Street Address City State ZIP Code

Phone

Relationship / Occupation

Years Known

Please enter a number less than or equal to 99.

Additional Information

If applying for Warehouse Position, Please indicate whether you hold the following valid driver’s licenses:

Class A

Class B

Class C

Driver's License Number:

State Issued

Date of late Department of Transportation prescribed physical examination.

Have you ever been granted a waiver under section 391.49 of the Federal Motor Carrier Safety Regulations pertaining to the loss of foot, hand or arm?

Yes

Have you ever been denied a license, permit or privilege to operate a motor vehicle?

Yes

Has any driving license, permit or privilege ever been suspended or revoked?

Yes

Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations?

Yes

Operation Experience

Straight Trucks

Type of Equipment (van, truck, flat)

From:

To:

Approximate Total Miles

Tractor Trailer

Type of Equipment (van, truck, flat)

From:

To:

Approximate Total Miles

Twin Trailers

Type of Equipment (van, truck, flat)

From:

To:

Approximate Total Miles

Other Equipment

Type of Equipment (van, truck, flat)

From:

To:

Approximate Total Miles

Accidents

Dates

Nature of Accident

Fatalities Y/N

Fatalities Number Of

Injuries Y/N

Injuries Number Of

Traffic Convictions

Dates

Traffic Convictions

Charge

Penalty

Are you willing to submit to a controlled substance test?

Yes

Are you willing to submit to random controlled substance tests if employed?

Yes

Are you willing to submit to a background check?

Yes

Have you ever been convicted of a criminal offense (felony or misdemeanor)?

Yes

Describe the nature of the crime(s), when and where convicted and disposition of the case

Election of Veteran's Preference

Do you wish to claim a veteran’s preference?

Yes

If so please check the preference you are claiming.

Veteran (defined as person separated under honorable conditions who has served on active duty for at least 181 days, or honorably discharged by reason of disability incurred while on active duty).

Disabled Veteran (a veteran having a compensable service connected disability as adjudicated by the U.S. Veterans Administration or the retirement board of one of the branches of the Armed Forces which disability is currently existing).

Spouse of deceased veteran.

Spouse of disabled veteran who is unable to use preference due to disability.

Veteran's Preference Documentation

Accepted file types: pdf, jpg, jpeg, gif, png, Max. file size: 10 MB.

Note: If you elect to use veteran’s preference, please enclose proper documentation establishing your right to claim the preference.

Signature

The Continuum, Restoration is an Equal Opportunity Employer. It is the policy of the Continuum, Restoration not to discriminate in employment matters on the basis of race, creed, color, age, marital status, national origin, sex, or status with regard to public assistance or disability.

Signature(Required)

I certify that the facts set forth in this application for employment are true and complete to the best of my knowledge. I understand that if employed, false statements on this application shall be considered sufficient cause of dismissal. If I am employed by Continuum, Restoration terms for my immediate expulsion may result if false statements and or other information comes to the attention of my manager or owners. You are hereby authorized to make investigation of my personal references.

WARNING

Continuum Restoration
405 Machine Loop
Scott, LA 70583

Continuum Restoration is required to inform you of your rights as they pertain to the private information collected from you. Private data is that information which is available to you, but not to the public. The personal information we collect about you is private.

The information collected from you or from other agencies or individuals authorized by you is used to determine your qualifications for the Continuum Restoration.

You are not legally required to provide this information; however, providing it may be necessary to determine if you qualify for employment. Disclosure of your social security number is voluntary, unless you are employed by the Continuum Restoration If employed by the Continuum Restoration, you must disclose it in order to be in compliance with state and federal tax withholding laws. If you do not supply the required information, the Continuum Restoration may not be able to consider you for employment. The use of the provided data we collect is limited to individuals whose jobs reasonably require access to this information. Persons or agencies with whom this information may be shared include:

Owners
Managers and Supervisors of Departments Where Job Openings Occur

Unless otherwise authorized by state statutes or federal law, other government agencies utilizing the reported private data must also treat the information as private.

Signature

I have read and understand the above information regarding my rights.

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Personal Information

Education

High School

College

Graduate School

Technical or Certificate Programs

Employment History

Employer 1:

Employer 2:

Employer 3:

Qualifications

References

Reference 1

Reference 2

Reference 3

Additional Information

Operation Experience

Straight Trucks

Tractor Trailer

Twin Trailers

Other Equipment

Election of Veteran's Preference

WARNING

your life, continued

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