Wichita’s Fireplace & Hearth Experts Since 1979
Thank you for your interest in applying for career employment with our company.
Behind this cover sheet you’ll find an application for employment with us in our office. We’re looking for individuals who
are looking for a career – not just a job.
Our clients are our families, friends and neighbors. They are our business associates. They are the friends of those
people as well. Our trusted team of employees enters our client’s homes and businesses and we want to make certain
that you are someone whom we can trust and someone who can work well with others as a team member. We take our
responsibility to serve our clients personally and professionally and with only the highest level of service we can provide to
them. 2nd best is simply not acceptable.
We only wish to employee the “Best of the Best”. If you aspire to be someone who is at the top of their field, read on.
If you’re looking for a fulfilling career where you’ll be challenged to learn on a daily basis and you’ll be personally
rewarded by knowing you help keep families safe from harm, read on.
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
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If you don’t consider yourself an honest person with good character, this is not the place for you.
If you use illegal drugs there’s no need to go any further. You won’t qualify to work here.
If you can’t pass a comprehensive 50-state criminal background check, there’s no need to go any further. You
won’t qualify to work here.
Does this seem a little harsh? Does this seem like something you’ve never heard of? It’s because we have very high
expectations of our employees and we make the following pledge to each and every customer. That pledge is on the
back of each and every business card we hand out. It states:
“It is our Personal Promise and Guarantee to Provide You With the Absolute Highest Level of Quality,
Comprehensive Customer Service & Care in the Hearth Service, Inspection and Installation Field”
So those are the basics. If you’ve made it to this point, please take the time to fill this application out fully and return it to
us A.S.A.P. Let us get to know you. Tell us why you feel you can be a contributing team member to the most successful
and most respected hearth company in the area. If we feel you are a potentially good fit for our organization, we’ll contact
you personally, even if we don’t have a position open at the current time, to let you know the status of this application.
Sincerely,
, President
Home Safe Hearth & Chimney, Inc.
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Home Safe Employment Application
Page 2 of 10
Revised 5/22/2014
Home Safe Hearth & Chimney, Inc.
Office Employment Application Form
Return By Mail or Personally To:
Home Safe Hearth & Chimney, Inc.
504 South St. Francis
Wichita, KS 67202
PLEASE PRINT LEGIBLY ALL
INFORMATION REQUESTED EXCEPT
SIGNATURE
APPLICATION FOR EMPLOYMENT
APPLICANTS WILL BE TESTED FOR ILLEGAL DRUGS AND
WILL BE SUBJECT TO A 50-STATE CRIMINAL BACKGROUND CHECK
DATE _________________________________
PLEASE COMPLETE PAGES 3-8 ONLY.
Name ______________________________________________________________________________________________
Last
First
Middle
Maiden
Current Address _____________________________________________________________________________________
Number
Street
City
State
Zip
Social Security No. _______ – _____ – _________
How long have you lived there?__________________________
Telephone(s) Indicate if Cell and indicate best number to reach you ______________________________________________
If under 18, please list age ____________________
Position applied for (1) _______________________
and salary/hourly pay desired (2) ____________________________
(Please Be Specific)
Days/hours available to work
No Pref _______ Thur _________
Mon _________ Fri __________
Tue _________ Sat __________
Wed _________ Sun _________
How many hours can you work weekly? ________________________
Employment desired
FULL-TIME ONLY
PART-TIME ONLY
FULL- OR PART-TIME
When are you or when would you be available for work?_______________________________________________________
____________________________________________________________________________________________________
TYPE OF SCHOOL
NAME OF SCHOOL
LOCATION
(Complete mailing address if possible)
# OF YEARS
COMPLETED
MAJOR &
DEGREE
High School
College
Bus. or Trade School
Professional School
HAVE YOU EVER BEEN CONVICTED OF ANY CRIME?
 No
 Yes
If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were
committed, sentence(s) imposed, and type(s) of rehabilitation.
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Home Safe Employment Application
Page 3 of 10
Revised 5/22/2014
PLEASE PRINT LEGIBLY ALL
INFORMATION REQUESTED
EXCEPT SIGNATURE
Employment Application
APPLICATION FOR EMPLOYMENT
DO YOU HAVE A VALID DRIVER’S LICENSE?
 Yes
 No
Please Note, We will run a DL Check.
What is your means of transportation to work? ______________________________________________________________
Driver’s License
Number ____________________________ State of Issue _______
Expiration date ______________________
 Operator
 Commercial (CDL)
Chauffeur
Have you had ANY accidents during the past 3 years? Number? & Describe________________________________________
____________________________________________________________________________________________________
Have you had ANY moving violations during the past 3 years? Number? & Describe_________________________________
____________________________________________________________________________________________________
Electronic Devices and Skills
 Yes  No
Can you Type?
_____ WPM
Do you know how to operate a Computer?  Yes
Do you have a cell phone/mobile device?  Yes
Do you have a tablet device?  Yes
 No
 No
 No
PC
 Mac
Brand?________________ Smart Device? _______________
Brand?______________________________________________________
Can you Operate a Word Processor Program?  Yes  No _____ WPM
Do you know how to work with Excel/Spreadsheets?__________________________________________
Do you know how to work with Microsoft Outlook?____________________________________________
Do you know how to work with Microsoft PowerPoint?____________________________________________
Other ____________________________________________
Please also use this space to describe your experience and experience level with computers and software as well. Describe
what operating system(s) you are familiar with and what other software programs you are familiar with.
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Please list two character references other than relatives or previous employers.
Name ________________________________________
Name ____________________________________________
Position ______________________________________
Position __________________________________________
Company _____________________________________
Company _________________________________________
Address ______________________________________
Address __________________________________________
______________________________________
__________________________________________
Telephone (
)
Telephone (
)
This person’s relationship to me is:
This person’s relationship to me is:
______________________________________________
______________________________________________
Home Safe Employment Application
Page 4 of 10
Revised 5/22/2014
PLEASE PRINT LEGIBLY ALL
INFORMATION REQUESTED
EXCEPT SIGNATURE
Employment Application
APPLICATION FOR EMPLOYMENT
MILITARY
HAVE YOU EVER BEEN IN THE ARMED FORCES?
 Yes
 No
 Yes
ARE YOU NOW A MEMBER OF THE NATIONAL GUARD OR ARMED FORCES?
 No
Specialty __________________________________ Date Entered ________________ Discharge Date ______________
Was Discharge Honorable?__________ If No, Why?__________________________________________________________
Work
Experience
Please list your work experience for the past five years beginning with your most recent job held.
If you were self-employed, give firm name. Please indicate if you are currently employed. Attach
additional sheets if necessary.
Name of Employer
Name of last
supervisor
Address
City, State, Zip Code
Phone number
Pay or salary
Employment
Dates
From
Start
To
Final
Your last job title
Reason for leaving or reason you are considering leaving, if currently employed at this business (Be Specific!)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this
company.
Name of Employer
Name of last
supervisor
Address
City, State, Zip Code
Phone number
Pay or salary
Employment
Dates
From
Start
To
Final
Your Last Job Title
Reason for leaving or reason you are considering leaving, if currently employed at this business (Be Specific!)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this
company.
Home Safe Employment Application
Page 5 of 10
Revised 5/22/2014
PLEASE PRINT LEGIBLY ALL
INFORMATION REQUESTED
EXCEPT SIGNATURE
Employment Application
APPLICATION FOR EMPLOYMENT
Work
experience
Please list your work experience for the past five years beginning with your most recent job held.
If you were self-employed, give firm name. Attach additional sheets if necessary.
Name of Employer
Name of last
supervisor
Address
City, State, Zip Code
Phone number
Pay or salary
Employment
Dates
From
Start
To
Final
Your last job title
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this
company.
Name of Employer
Name of last
supervisor
Pay or salary
Employment
Dates
Address
City, State, Zip Code
Phone number
From
Start
To
Final
Your last job title
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this
company.
May we contact your present employer(s)?
 Yes
 No
If No, Why?_________________________________________
____________________________________________________________________________________________________
Did you complete this application yourself?
 Yes
 No
If No, who completed this application for you?
____________________________________________________________________________________________________
Home Safe Employment Application
Page 6 of 10
Revised 5/22/2014
A job application sometimes doesn’t tell the “rest of the story”.
Here’s your chance to tell us some things about you.
Please answer the following 2 questions.
1.
How do you feel about money?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
2.
Why should we hire YOU?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Home Safe Employment Application
Page 7 of 10
Revised 5/22/2014
PLEASE READ CAREFULLY!
APPLICATION FORM WAIVER
In exchange for the consideration of my job application by Home Safe Hearth & Chimney, Inc. (hereinafter
called “the Company”), I agree that:
Neither the acceptance of this application nor the subsequent entry into any type of employment
relationship, either in the position applied for or any other position, and regardless of the contents of
employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist
from time to time, or other Company practices, shall serve to create an actual or implied contract of
employment, or to confer any right to remain an employee of Home Safe Hearth & Chimney, Inc. or
otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and
that relationship cannot be altered except by a written instrument signed by the President /General Manager
of the Company. Both the undersigned and Home Safe Hearth & Chimney, Inc. may end the employment
relationship at any time, without specified notice or reason. If employed, I understand that the Company
may unilaterally change or revise their benefits, policies and procedures and such changes may include
reduction in benefits.
I authorize investigation of all statements contained in this application. I understand that the
misrepresentation or omission of facts called for is cause for dismissal at any time without any previous
notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise
indicated), references, and others, and hereby release the Company from any liability as a result of such
contract.
I also understand that (1) the Company has a drug and alcohol policy that provides for preemployment
testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of
my employment; and (3) continued employment is based on the successful passing of testing under such
policy. I further understand that continued employment may be based on the successful passing of jobrelated physical examinations.
I understand that, in connection with the routine processing of your employment application, the Company
may request from a consumer reporting agency an investigative consumer report including information as to
my credit records, driving record, character, general reputation, personal characteristics, and mode of living.
Upon written request from me, the Company, will provide me with additional information concerning the
nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act.
I further understand that my employment with the Company shall be probationary for a period of one
hundred twenty (120) business days, and further understand that at any time during the probationary period
or thereafter, my employment relation with the Company is terminable at will for any reason by either party.
Signature of applicant__________________________________________ Date: ___________________
This Company is an equal employment opportunity employer. We adhere to a policy of making employment
decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or
disability. We assure you that your opportunity for employment with this Company depends solely on your
qualifications.
Thank you for completing this application form and for your interest in our business!
Please Do NOT fill out pages 9 and 10.
Home Safe Employment Application
Page 8 of 10
Revised 5/22/2014
PLEASE PRINT LEGIBLY ALL
INFORMATION REQUESTED
EXCEPT SIGNATURE
POST EMPLOYMENT INFORMATION FORM
TO BE COMPLETED AFTER EMPLOYEE HAS BEEN HIRED
Height ______ ft. ______ in.
Married  Yes
 No
Weight __________
If married, how long? _____
Birth date _______________
 Single
 Separated
Divorced
Widowed
Full name of Spouse ________________________________ Spouse’s Occupation ______________________________
Name of Company _________________________________ Work Telephone (
)
PERSON TO BE NOTIFIED IN CASE OF EMERGENCY
Name ___________________________________________ Telephone (
)
Address __________________________________________ Relationship _____________________________________
FOR INSURANCE PURPOSES ONLY: LIST ALL DEPENDENTS
NAME
RELATIONSHIP
BIRTH DATE
SSN
TO BE COMPLETED
BY EMPLOYER
50-State Comprehensive Criminal Background Test Confirmation by _____________________________________________
Drug Test Confirmation Number ______________________________
Pulmonary Test Reference Number & Doctor Performing Exam__________________________________________________
DOT Physical Reference Number & Doctor Performing Exam __________________________________________________
Driver’s License Records Confirmed by ____________________________________________________________________
Other Records Confirmed and by__________________________________________________________________________
____________________________________________________________________________________________________
Skills Test Type & Given By ____________________________________________________________________________
Skills Test Type & Given By ____________________________________________________________________________
Skills Test Type & Given By ____________________________________________________________________________
Name of person verifying references, employment history, etc… ________________________________________________
Name of person authorizing employment ___________________________________________________________________
Date of Employment __________________ Job title ____________________ Dept. _____________________________
Location ____________________________ Rate of pay _________________
 Full-time  Part-time  Salaried
Applicant’s Signature and Date Acknowledging Above Information _______________________________________________
Home Safe Employment Application
Page 9 of 10
Revised 5/22/2014
Applicant Selection Criteria Record
JOB TITLE
CANDIDATES CONSIDERED (INCLUDING MINORITIES AND FEMALES)
MALE/
FEMALE
NAME
ETHNIC
CODE*
APPLICATION
DATE
*ETHNIC CODES: 1-BLACK, 2-ORIENTAL, 3-HISPANIC, 4-AMERICAN INDIAN, 0-OTHER
CANDIDATE SELECTED
NAME
MALE/
FEMALE
ETHNIC
CODE
SOURCE
SELECTION CRITERIA
REASONS CANDIDATE SELECTED WAS PREFERABLE TO OTHERS
ORIGINATOR'S SIGNATURE
Home Safe Employment Application
Page 10 of 10
DATE
Revised 5/22/2014