Santa Rosa Application for Employment

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.

First Name *

Middle Name *

Last Name *

Date of Birth *

Email Address *

Phone Number *

Current Address Street *

Current Address City *

Current Address State *

Current Address Zip *

Previous Address Street

Previous Address City

Previous Address State

Previous Address Zip

Do you have a legal right to be employed in the United States? *

Yes

No

Are you over the age of 18? *

Yes

No

Have you ever been convicted of a crime, excluding misdemeanors? *

Yes

No

If so, explain in full *

Company Experience

Have you worked for this company before? *

Yes

No

Start date *

End Date *

Where? *

Rate of Pay *

Position *

Reason for Leaving *

General

Are you currently employed? *

Yes

No

If not, when was your last day employed? *

Position Applied For

Full Time

Yes

Part Time

Yes

Temporary Position

Yes

Summer Position

Yes

Start Date *

Desired Salary *

Referred By

Do you have any relatives by blood, by marriage, by adoption or by living together working at this Cooperative? *

Yes

No

If yes, please indicate relationship and persons to whom you are a relative *

Education

High School Attended and Location

Number of years completed

Did you graduate?

Yes

No

College Attended and Location

Number of years completed

Did you graduate?

Yes

No

Trade, Business or Correspondence School

Number of years completed

Did you graduate?

Yes

No

Special Courses and/or Training:

Experience/Skills Related To The Position For Which You Are Applying:

Office/Secretarial Applications

Please check the following skills for which you have received training:

Microsoft Word Processing

PC/Mac

Typewriter

Customer Service

Words Per Minute? *

Excel Spreadsheets

Copier

Fax Machine

Accounting

Multi Line Phone

Cash Drawer/Balancing

10---Key

Data Entry

Other

Outside/Construction Applications

Please check the following skills for which you have received training:

Commercial Drivers License (CDL)

Cable Plowing Equipment

Boring Machine

Semi Truck Driver

Installation of Telephones/Cable TV

Telephone/Cable TV Terminology

Drop Plow

Trenching/Ditching

Fiber Testing/Installation

Digital Switch

Splicing of Fiber

Copper Wiring

Backhoe

Other

Personal References (No former employees or relatives)

Reference 1 Name *

Reference 1 Occupation *

Reference 1 Relationship *

Reference 1 Phone Number *

Reference 2 Name *

Reference 2 Occupation *

Reference 2 Relationship *

Reference 2 Phone Number *

Reference 3 Name *

Reference 3 Occupation *

Reference 3 Relationship *

Reference 3 Phone Number *

Work References

Work Reference 1 *

Relationship and Title *

Company *

Phone Number *

Street Address *

City *

State *

Zip *

Years Known *

Work Reference 2 *

Relationship and Title *

Company *

Phone Number *

Street Address *

City *

State *

Zip *

Years Known *

How many previous jobs do you have that you want to provide information on? *

Employment History 1

Company 1 (Most Recent) *

Address *

Phone *

Type of Business *

Your Position *

Duties *

Name of Immediate Supervisor *

May We Contact? *

Yes

No

Starting Pay

Final Pay

Was this hourly or salary pay?

Hourly

Salary

Date Employed *

Date Left *

Reason For Leaving *

COMMERCIAL DRIVERS ONLY:

Were you subject to the FMCSRs+ while employed?

Yes

No

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the Drug and Alcohol Testing Requirements of 49 CFR Part 40?

Yes

No

Employment History 2

Company 2

Address

Phone

Type of Business

Your Position

Duties

Name of Immediate Supervisor

May We Contact?

Yes

No

Starting Pay

Final Pay

Was this hourly or salary pay?

Hourly

Salary

Date Employed

Date Left

Reason For Leaving

COMMERCIAL DRIVERS ONLY:

Were you subject to the FMCSRs+ while employed?

Yes

No

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the Drug and Alcohol Testing Requirements of 49 CFR Part 40?

Yes

No

Employment History 3

Company 3

Address

Phone

Type of Business

Your Position

Duties

Name of Immediate Supervisor

May We Contact?

Yes

No

Starting Pay

Final Pay

Was this hourly or salary pay?

Hourly

Salary

Date Employed

Date Left

Reason For Leaving

COMMERCIAL DRIVERS ONLY:

Were you subject to the FMCSRs+ while employed?

Yes

No

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the Drug and Alcohol Testing Requirements of 49 CFR Part 40?

Yes

No

Employment History 4

Company 4

Address

Phone

Type of Business

Your Position

Duties

Name of Immediate Supervisor

May We Contact?

Yes

No

Starting Pay

Final Pay

Was this hourly or salary pay?

Hourly

Salary

Date Employed

Date Left

Reason For Leaving

COMMERCIAL DRIVERS ONLY:

Were you subject to the FMCSRs+ while employed?

Yes

No

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the Drug and Alcohol Testing Requirements of 49 CFR Part 40?

Yes

No

Employment History 5

Company 5

Address

Phone

Type of Business

Your Position

Duties

Name of Immediate Supervisor

May We Contact?

Yes

No

Starting Pay

Final Pay

Was this hourly or salary pay?

Hourly

Salary

Date Employed

Date Left

Reason For Leaving

COMMERCIAL DRIVERS ONLY:

Were you subject to the FMCSRs+ while employed?

Yes

No

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the Drug and Alcohol Testing Requirements of 49 CFR Part 40?

Yes

No

Vehicle Operators Information (All applicants must complete)

LIST ALL DRIVER LICENSES OR PERMITS HELD IN THE PAST 3 YEARS:

License 1 State Issued

License Number

Type

Expiration Date

License 2 State Issued

License Number

Type

Expiration Date

License 3 State Issued

License Number

Type

Expiration Date

Accident Record

ACCIDENT RECORDS FOR THE PAST 3 YEARS OR MORE (ATTACH ADDITIONAL SHEET IF NECESSARY) IF NONE, WRITE NONE

Most Recent

Nature of Accident

Fatalities

Injuries

Hazardous Material Spill

Next Current

Nature of Accident

Fatalities

Injuries

Hazardous Material Spill

Next Current

Nature of Accident

Fatalities

Injuries

Hazardous Material Spill

Traffic Convictions

PLEASE LIST ANY TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE.

Location

Date

Charge

Penalty

Location

Date

Charge

Penalty

Location

Date

Charge

Penalty

HAS ANY LICENSE, PERMIT OR PRIVILEGE EVER BEEN SUSPENDED OR REVOKED?

Yes

No

HAVE YOU EVER BEEN DENIED A LICENSE, PERMIT OR PRIVILEGE TO OPERATE A MOTOR VEHICLE?

Yes

No

IF YOU ANSWERED YES TO EITHER ABOVE OR BOTH PLEASE EXPLAIN:

Driving Experience

Straight Truck

Van, Tank, Flat, Dump 1

Van, Tank, Flat, Dump 2

From

To

Tractor and Semi-Trailers

Van, Tank, Flat, Dump 1

Van, Tank, Flat, Dump 2

From

To

Tractor-Two Trailers

Van, Tank, Flat, Dump 1

Van, Tank, Flat, Dump 2

From

To

Tractor-Three Trailers

Van, Tank, Flat, Dump 1

Van, Tank, Flat, Dump 2

From

To

Motorcoach-School Bus 8 Pass

From

Date

Motorcoach-School Bus 15 Pass

From

To

List States operated in for the last five years:

Indicate special courses or training that will assist you as a driver:

Do you currently have any safe driving awards, if so from whom?

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