Employment Application



Please print out the application below. Fax the completed application to us at:

FAX: 405-524-7878

Utility Services Associates Construction Co. Inc.
ATTN: Personnel
2301 West I-44 Service Rd.
Investment Plaza, Ste. 101
Oklahoma City, OK 73112
405-524-7788
jobs@usaccoinc.com


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APPLICATION FOR EMPLOYMENT
(PRE-EMPLOYMENT QUESTIONNAIRE)
(AN EQUAL OPPORTUNITY EMPLOYER)


PERSONAL INFORMATION

NAME: (Last) _______________________________ (First) _______________________ (Middle)_______________

PRESENT
ADDRESS:
(Str) ______________________________________ (City) ______________________ (Zip) __________

PERMANENT
ADDRESS:
(Str) ______________________________________ (City) ______________________ (Zip) __________

PHONE NO. (________)_______________________ SOC. SEC. NUMBER: ___________-_______-______________

Are you either a U.S. citizen or an alien authorized to work in the United States? Yes No

SPECIAL QUESTIONS

Do not answer any of these questions at this time. However, your employer may asked that you complete some of the questions later, indicating that the information is required for a bona fide occupational qualification, is dictated by national security laws, or is needed for other legally permissible reasons.

Height: _______feet ______inches Weight: _______lbs. Date of Birth* ___________________

Are you a U.S. citizen? Yes No

What foreign languages do you speak fluently? ________________________________________________________

Read? ___________________________________ Write? ___________________________________

Have you been convicted of a felony or misdemeanor within the last 5 years?** No Yes

If yes, describe: ___________________________________________________________________________

_____________________________________________________________________________________________

I understand and agree that I may be required to take one or more: ____ Physical examiniation; ____ lie detector test(s), as a condition of hiring or continued employement. I agree to consent to take such test(s) at such time as designated by the Company and to release the Company, its directors, officers, agents or employees from any claim arising in connection with the use of such test(s).
Yes No
I have been advised that lie detector tests, as a condition of hiring or continued employment, are prohibited by law.
Yes No

*The Age Discrimination in Employment Act of 1967 pohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age.

** You will not be denied employment solely because of a conviction record, unless the offense is related to the job for which you have applied.


 

EMPLOYMENT DESIRED

POSITION: _____________________________ DATE YOU CAN START:___________________________

ARE YOU EMPLOYED NOW? No Yes
IF SO, MAY WE INQUIRE OF YOUR PRESENT EMPLOYER? No Yes

EVER APPLIED TO THIS COMPANY BEFORE? No Yes
IF YES, WHERE? ___________________________ WHEN? ____________________________


EDUCATION

List schools attended. (Include high school and all trade, business or correspondence schools. List specific certificates and licenses earned.)
____________________________________________________________________________________________

____________________________________________________________________________________________


GENERAL

List subjects of special study or research work: _____________________________________________________

____________________________________________________________________________________________

U.S. MILITARY OR NAVAL SERVICE: ______________________________ RANK: _______________________

PRESENT MEMBERSHIP IN NATIONAL GUARD OR RESERVES: No Yes

 

FORMER EMPLOYERS
(List your last 3 employers, starting with the last one first.)
Date
Month & Year
Name and Address
of Employer
Salary Position Reason for Leaving
From

To
From

To
From

To

 

REFERENCES
(Give the names of 3 persons not related to you, whom you have know at least 1 year.)
Name Address Business Years Acquainted
1.

2.

3.

 

PHYSICAL RECORD:
Do you have any physcial limitations that preclude you from performing any work for which you are being considered?

No Yes If yes, what can be done to accommodate your limitation? ____________________

_______________________________________________________________________________________


IN CASE OF EMERGENCY, NOTIFY:

Name _______________________________________________________________________

Address _____________________________________________________________________

Phone Number ________________________________________________________________

"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statments on this application shall be grounds for dismissal.
I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnising same to you.
I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without prior notice."



DATE: _____________________ SIGNATURE: ______________________________________________________
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