Tribble Electric, Inc.
Application for Employment
(Please Print)
We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including age,
sex, color, race, creed, national origin, religious persuasion, marital status, political belief or disability that does not prohibit
performance of essential job functions.
Date:
I. Personal Information
_____
Name:
Last
First
Middle
Present Address
Permanent Address (if different than above)
Social Security Number
Telephone
Federal law prohibits the employment of unauthorized aliens. All persons hired must submit satisfactory proof of
employment authorization and identity (valid driver’s license, birth certificate, Green Card, etc.) within three days of
being hired. Failure to submit such proof within the required time shall result in immediate employment termination.
Position Applied For:
1. Is there any information we would need about your name or use of another name for us to be able to check your
work record? Please specify:___________________________________________
2. Are you over the age of 18 years? ___Yes ___No (If no, you may be required to provide authorization)
3. Can you with or without reasonable accommodation perform the essential functions of this job? ____Yes ___No (job
requirements include but not limited to crawling in crawl spaces and in attics, lifting 50-75 lbs, walking up and down steps
and ladders, bending, squatting, digging, using hand tools) (If you have any questions about the functions of the job, please
ask the interviewer before answering this question.)
If no, please explain _______________________________________________________________________
4. Do you have any relatives who are presently (or have formerly been) employed by Tribble Electric, Inc.?
Explain__________________________________________________________________________________
5. Have you ever been employed by Tribble Electric Electric, Inc.?
If yes, indicate dates of employement_____________________________________________________________
6.
How were you referred to Tribble Electric, Inc.?__________________________________________________
7. Have you ever been convicted of a felony or misdemeanor? ___ Yes___ No
If yes, please explain:_______________________________________________________________________
8. Do you have a valid Virginia driver’s license for at least 3 years? ___Yes ___No
If no, explain___________________________________________________________________________
9. Do you have reliable transportation to work? ___ Yes ___ No
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10. Have you been convicted of any moving violations in the past five years? ___Yes ___No
If yes, please explain:_____________________________________________________________________
11. Have you ever been fired or asked to resign from a job? ___Yes ___No
If yes, please explain:_____________________________________________________________________
12. Do you have any commitments over the next 12 months that would require you to take time off?
___Yes ___No If yes, please explain ______________________________________________________
II. Educational History
School Name/Location
Years Completed
Degree/Diploma
Elem/Jr. High
High School
College
Tech. Training
Please list any academic honors, scholarships, offices held, etc. (Do not list any which reflect your race, color, religion, gender, national
origin, age, disabilities or veteran status)
Describe any specialized training, apprenticeships, licenses or skills
_______________________________________________________________________________________
III. Employment Record
Please include all employment for the last five years.
1.
Company Name (Current or Most Recent Employer)
Position Held
Dates Employed:
Address
Manager / Supervisor
From
To
Telephone
Wage/Salary
Reason For Leaving
2.
Company Name
Position Held
Dates Employed:
Address
Manager / Supervisor
From
To
Telephone
Wage/Salary
Reason For Leaving
3.
Company Name
Position Held
Dates Employed:
Address
Manager / Supervisor
From
Telephone
Reason For Leaving
2
To
Wage/Salary
NOTE: Use a separate sheet to list additional employers, if necessary. We will contact all of the employers listed on this applicat ion unless
you specifically exclude them below. Please list any employers you do not want us to contact and your reason for the exclusion:
(Employer’s Name)
Reason
(Employer’s Name)
Reason
IV. References
Please do not include relatives or former employers.
1.
____
Name
Years Known
Address
Telephone
Occupation
2.
Name
Years Known
Address
Telephone
Occupation
3.
Name
Years Known
Address
Telephone
Occupation
V. Work Availability
1.
If your application receives favorable consideration, when will you be available to begin work?
2.
3.
4.
5.
6.
Do you have any objection to working overtime?
Can you work overtime without prior notice?
Can you work on Saturday?
Can you work on Sunday?
Can you travel if required by this position?
(
(
(
(
(
) Yes
) Yes
) Yes
) Yes
) Yes
(
(
(
(
(
) No
) No
) No
) No
) No
VI. Salary / Hourly Rate Requirements
If your application receives favorable consideration, what salary/hourly rate would you require?
$
per
Revised 6/8/2011
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********** COMPANY USE ONLY **********
Interview Date: ____/____/____ Interviewed by: ____________________________________________
Order Driving Record?
YES
NO
Driving Record Complete
Reference Check Complete
Drug Test Complete
Criminal Background Check Complete
Not Hired/No longer considering for employment
Hired
Estimated Start Date (on or about): ____/____/____
Wage: $ ________ per ________ (hour/week/annual)
Reports to: ___________________________________________________
Job Title: _____________________________________________________
If Electrician, Licensed Journeyman?
YES
NO If yes, obtain copy of card.
If Apprentice, what year? ______ If Apprentice, complete the “SELECTION PROCEDURE FORM”
Is an offer letter required?
YES
NO
Items to Assign:
Cell?
YES
NO
Truck?
YES
NO
Other Issued Item(s):
_______________________________________________________________________________________
Notes:
_______________________________________________________________________________________
_______________________________________________________________________________________
Steve Tribble’s Signature: __________________________________________ Date: ____/____/____
Employee’s Signature: _____________________________________________ Date: ____/____/____
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