STAFF ELECTRIC CO., INC.
APPLICATION FOR FIELD EMPLOYMENT
Madison Only
Staff Electric is an equal opportunity employer and fully subscribes to the principles of Equal
Employment Opportunity. It is the policy of this company to provide employment, compensation and
other benefits related to employment based on qualifications without regard to race, religion, color,
national origin, sex, creed, age, disability, ancestry, sexual orientation, marital status, arrest record,
conviction record (unless substantially related to the job), membership in the National Guard or
Reserves, use or non-use of lawful products off company premises during non-working hours, or any
other category protected by federal, state or local law. As an equal opportunity employer, this
company intends to comply fully with all federal and state laws. The information requested on this
application will not be used for any purpose prohibited by law. Disabled applicants may request any
needed accommodation.
INSTRUCTIONS TO APPLICANT:
1. COMPLETE ALL INFORMATION requested.
2. PRINT answers clearly.
3. SIGN and DATE application.
Name
(Last)
_
(M.I.)
(First)
Date
__
Address
__
__
City
State
Zip Code
HOME:
Email Address
CELL:
Telephone
__
If used any other name, please state
POSITION APPLIED FOR:
Journeyman Inside Wireman
Have you previously worked for Staff Electric Co.?
From
Construction Wireman (CW)
Construction Electrician (CE)
VDV Technician
VDV Installer
Residential
Delivery Driver
To
Month / Year
Apprentice Inside Wireman
Yes
From
_
Month / Year
To
Month / Year
Reason for Leaving
No
_
Month / Year
_
-- Page 2 --
EMPLOYMENT INFORMATION
Are you legally authorized to work in the United States ?
Are you at least 18 years old?
Yes
Yes
No
No
After work-related accidents or when the company has reasonable suspicion to believe an
employee is using or abusing drugs, employees must take a drug and alcohol test. Can you
comply with this policy?
Yes
No
Do you have the ability to get to work within a 75-mile radius?
Yes
No
Do you have the ability to perform all essential job functions with or without reasonable
accommodation for the position you are applying?
Yes
No
If not, please explain
Have you ever pled guilty to or been convicted of a felony or crime for any offense or violation other
than minor traffic offenses?
Yes
No Please list all in space below.
(Note: A conviction does not automatically preclude you from employment.)
Do you have any pending criminal charges against you?
Yes
No
Please list all charges in space below.
(Note: A pending charge does not automatically preclude you from employment.)
Charge
Date
Location
Disposition of Case
(Conviction / Pending / Dismissed)
-- Page 3 --
EXPERIENCE
Are you a graduate apprentice?
Yes
No If not, when did you pass the journeyman’s
test at the union? _______________ (Date)
Number of years experience in electrical construction trade ________
Have you ever been employed as a foreman?
Company
Yes
No
Project
From
To
WI License, Certifications, Registrations:
I.D. Number
Expiration Date
Master Electrician
__________________
__________________
Journeyman Electrician
__________________
__________________
Electrical Apprentice
__________________
__________________
Registered Electrician
__________________
__________________
__________________
__________________
Other Category or State
_____________________
TRAINING
OSHA 10
NFPA 70E
First Aid
Yes
Yes
Yes
No
No
No
CPR
Scissors Lifts
Forklifts
Yes
Yes
Yes
No
No
No
OSHA 30
Fall Protection
Yes
Yes
No
No
Please list courses you have taken at JATC or other outside venues in last two (2) years:
SPECIALIZED SKILLS
Are you proficient in any of the following skills:
Y
-
Motor Controls
Fire Alarm & Security
Telecommunications
Pipe Bending (larger than 2”)
Medium Voltage ( >600 v)
N
Project
From
To
Comments
-- Page 4 --
EMPLOYMENT HISTORY
List all present and past employment for the past three (3) years beginning with the most recent. Please
use another page if necessary.
Company Name
Dates Worked
(From)
(To)
Duties / Responsibilities
EMERGENCY CONTACT INFORMATION
(This information is voluntary and will be kept confidential)
Name
Relationship to
Employee
Phone Number
Work / Home
Cell Phone
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
(
)
-- Page 5 --
PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY BEFORE SIGNING YOUR NAME
I HEREBY CERTIFY that the answers provided by me to the above questions and statements are
true and correct and hereby authorize Staff Electric Co. to contact references, past or present
employers, persons, schools, law enforcement agencies, and any other sources of information,
including a background check, which may be relevant to my application of employment. It is
understood and agreed that any misrepresentation, false statement or omissions by me in this
application will be sufficient reason for rejection of my application or for dismissal at any time
during my employment without liability to Staff Electric Co. This includes furnishing a false
name or social security number.
I have read, understand and agree to the above statement: ________ (Please initial here)
I further understand that no representative of the Company has the authority to enter into any
agreement for employment for any specified period of time and that this Company is not
guaranteeing employment for anyone. No employment contract is created by virtue of my being
hired by this Company, and, if hired, my employment will be at will and may be terminated at any
time without prior notice.
I have read, understand and agree to the above statement: ________ (Please initial here)
If employed, I agree to abide by all of the work and safety rules of Staff Electric. I understand that
Staff Electric is committed to maintaining a drug-free workplace. I am aware that the Company
may require a drug test as part of the hiring process for driving positions. Also, if employed, I
realize that Staff Electric conducts post-accident and reasonable suspicion, drug and/or alcohol
testing of its employees.
I have read, understand and agree to the above statement: ________ (Please initial here)
I understand that this application will remain on file for 60 days for consideration. After 60 days,
if I am still interested in a position with this company, it will be necessary for me to complete a
new application form.
SIGN HERE ___________________________________________
DATE ______________________