Application for Employment

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Eagle Rock Concrete, LLC is an Equal Opportunity Employer.

Please Fill Out Entirely.

Position You Desire*

Date Available for Work*

Desired Salary*

Referred By

How did you hear about us?*

Please tell us where you heard about us...

Personal Information

Name*

First Middle Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Social Security Number*

Can you legally work in the United States of America?*

Yes
No

Have you ever been convicted of a felony?*

Yes
No

If yes, please explain:

Education

Please fill out the fields below for any education you have received. Use the plus button on the right to add more rows if you went to multiple schools.

High School*

School Name and Location	Years

College

School Name and Location	Years	Degree	Major

Post College

School Name and Location	Years	Degree	Major

Other

School Name and Location	Years	Degree	Major

In addition to your work history, are there other skills, qualifications, or experience that we should consider?

Personal References

Please provide up to three references that we may contact and are not previous employers.*

Name	Relationship to You	Company	Phone

Employment History - Past 10 Years

Notice to all Mixer Truck Driver Applicants: The U.S. Department of Transportation requires that all driver applicants show all employment for the past three years. Effective July 1987, applicants must also show all commercial driver employment for the seven years immediately preceding this three year period (10 years total). 391.21. (b)(10)(11)

Please provide all information.

List below present and past employment, beginning with the most recent.*

Name and Address of Company	From (Month / Year)	To (Month / Year)	Starting Hourly Rate	Ending Hourly Rate	Telephone	Name of Supervisor	Describe the work you did	Reason for Leaving

Click the plus button on the right to add a new row.

Additional Information for Commercial Drivers

The following information is required by the U.S. Department of Transportation, Section 391.21. Your application will not be considered if all information is not furnished.

Previous Residency

Please furnish the addresses at which you resided during the 3 years preceding the date on which the application is submitted.

Address	Street	City	State	Duration

Do you have a valid CDL?*

Yes
No

Commercial Motor Vehicle Operator's License

Please furnish the issuing State, number, and expiration of each unexpired commercial motor vehicle operator's license or permits that have been issued to you

State	Number	Expiration	License or Permit

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

Yes
No

If so, please explain:

Has one ever been suspended?

Yes
No

If so, please explain:

Have you ever been disqualified for violation of Safety Regulations?

Yes
No

If so, please explain:

Past Experience

Please list below the nature and experience in the operation of heavy equipment, including the type of equipment (such as mixer trucks, loaders, excavators, etc.) which you have operated.

Nature (i.e. hauled construction material)	Experience (Years)	Type of Vehicle

Motor Vehicle Accidents and Violations

Please list all of the motor vehicle accidents and violations in which you have been involved during the 10 years preceding the date of application.

Date	Nature	Fatalities or Personal Injuries (explain)

Notice to Applicant

All information submitted will be considered in reviewing my application and is subject to investigation. I hereby authorize Eagle Rock Concrete, LLC to investigate all statements applicable, except as indicated.
I certify that the facts set forth in this employment application are true and complete to the best of my knowledge. I understand that misrepresentation or omission of facts called for is cause for dismissal upon discovery of such information.
If accepted for employment, I hereby agree to comply with the rules, regulations, and policies of Eagle Rock, LLC.
I agree, if hired, to periodic checks of my background information by Eagle Rock Concrete, LLC to ensure I am upholding the standards of conduct and good driving record required by Eagle Rock Concrete, LLC for continued employment.
I understand that Eagle Rock Concrete, LLC is an "At Will" employer and that absolutely no contract of employement is offered nor implied by Eagle Rock Concrete, LLC.

Drug Program Disclosure and Agreement

As stated in the Associate's Handbook, Eagle Rock Concrete's drug detection policy is as follows:
The illegal use, possession , sale or transfer of alcohol, drugs, controlled substances, and illegal narcotics while on the job or Company property will result in immediate discharge and may result in an investigation by local authorities. Associates and/or applicants will be sunject to testing for drugs and/or alcohol under the following circumstances:

Pre-employment Testing - All applicants will be given a drug-screening test prior to hire.
DOT Testing - per DOT regulations
Reasonable Cause Testing - When a supervisor has reasonable cuase to question an Associate's condition.
Post Accident Testing - When an Associate is involved in an accident, on or off Company property while on Company time.
Random Testing - Associates selected at random.

Background Check

After submitting this application, you must complete the background check form on the next screen!

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge. I have also read and understand the above Notice to the Applicant and Drug Program Disclosure Agreement.

Applicants Full Name:*

Applicant's Signature*

By typing "I Agree" into this box you certify that you agree to the above statements.

Date*

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