Name Address City State Zip Code Email Phone Number Are you 18 years or older? YesNo Date of Birth Do you currently have a valid driver's license? YesNo Drivers License Number Do you have a CDL? YesNo Position Applied for: General LaborFlaggerTruck DriverOfficeManagementOther If you selected other, please specify: Acceptable Pay Rate Available Starting Date Can you perform the duties of the job in which you wish to be employed with or without accommodation? WithWithout Have you ever convicted a felony? YesNo Have you ever been involved in any moving violations? YesNo If yes, please explain: Have you ever been employed with Smith Construction before? YesNo If yes, please provide dates and reason for leaving Please list any allergies or other important medical information we should be aware of in the event of a medical emergency EDUCATION High School Attended Degree Type: DiplomaGEDN/A City/State of High School ADDITIONAL EDUCTION SchooL Degree Major GPA PERSONAL REFERENCES PROFESSIONAL REFERENCES EXPERIENCE (List Most Recent Employer First) Employer 1 Employer Address Title Responsibilities Dates of Employment Reason for Leaving Employer 2 Employer Address Title Responsibilities Dates of Employment Reason for Leaving Employer 3 Employer Address Title Responsibilities Dates of Employment Reason for Leaving Please Attach a Copy of your Resume Please Attach a Cover Letter (if applicable) I hereby give you my permission to contact the above employers, references, and educational institutions to verify the items I listed above. I hereby release Smith Construction, Inc., and the above reference person and employers from all claims, liability and damages that may result from furnishing the information to you. I expressly and fully waive all written notice from all prior employers. I further specifically waive written notice and agree to the divulging of any disciplinary reports, letters of reprimand or other disciplinary action by all prior employers and hereby release my prior from all claims, liability and damage that may result from furnishing the information to you. I authorized Smith Construction, Inc., to request a copy of my driving record information for purposes of investigation as required by Sections 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations. By typing your first and last name in the box below you authorize and release the above information to Smith Construction, Inc.