Employment Application - Branscome Paving, Manassas, VA

 Application for Employment Branscome Paving Company Participates in E -­‐ Verify Position Applying For (please circle): Laborer Traffic Control Operator Other_____________ CDL (DOT Medical Card Expiration Date________________________________) Date of Application: __________________________ Name _______________________________________________________________________________________________ First M.I. Last Telephone Numbers _____________________________________________ _______________________________ Home Cell List your addresses of residency for the past 3 years: Current Address ______________________________________________________________________________________________ Street City State Zip Previous Addresses _____________________________________________________________________________________________ Street City State Zip _____________________________________________________________________________________________ Street City State Zip _____________________________________________________________________________________________ Street City State Zip Date of Birth ______/_______/________ Social Security No. ___________-­‐-­‐_____________-­‐-­‐_______________ Month / day / year Have you worked for this company before____________________________? Dates: From__________ To ________ Reason for leaving _____________________________________________________________________________________ Who, if any one, referred you to Branscome Paving Company? ___________________________________________________ Are you currently employed___________________________? If yes, may we contact your employer __________? Are you prevented from lawfully becoming employed in this country because of Visa or Immigration status? __________ (Proof of citizenship or immigration status will be required upon employment) Branscome Paving Co. Application REV. 2015 1 On what date would you be available to start work? ______________ Are you available to work nights? _______________________ Are you available to work weekends? __________________________ Can you travel to job site? _____________________________ To operate any company vehicles/equipment applicant must provide valid driver’s license & complete MVR Request form: Issuing state of Driver’s License_______________ Driver’s License Number _________________ Exp. _________ Provided current driving record (DMV) _________ DRIVER EXPERIENCE & QUALIFICATIONS: (required by all applicants) A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? YES_______ NO_____ B. Has any license, permit or privilege ever been suspended or revoked? YES ______ NO_____ C. Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations? YES ______ NO_____ (If you answered “yes” to A, B, C attach a statement giving details) Drivers Licenses held
in past 3 years must
be shown
State
License No. Class
Endorsement(s)
Expiration Date
DRIVING EXPERIENCE Class of Type of Equipment (Van, Equipment
Tank, Flat, etc.)
Straight Truck
Tractor and Semi-­‐Trailer
Date From Date To
Apporximate Total Miles
Tanker
Other
List special courses or training that will help you as a driver ___________________________________________ List states operated in during last five years________________________________________________________ List driving awards held and who awards were presented by __________________________________________ ACCIDENT REVIEW FOR PAST 3 YEARS (Attach separate sheet of paper if more space is needed) Dates
Nature of accident (Head-­‐On, Rear -­‐End, Overturn, etc.)
Fatalities
Injuries
Last Accident
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Branscome Paving Co. Application REV. 2015 2 TRAFFIC CONVICTIONS & FORFEITURES FOR THE PAST 3 YEARS (other than parking violations) Location
Date
Charge
Penalty
Have you ever been convicted of a felony? ___________________________________________________________________ If yes, please explain fully on a separate sheet of paper. Conviction of a crime is not an automatic bar to employment – all circumstances will be considered. Is there any reason you might be unable to perform the functions of the job for which you have applied? If yes, explain if you wish. _____________________________________________________________________________________________________________ EXPERIENCE & QUALIFICATIONS: List courses and training that you have completed that would assist your employment with this company. _____________________________________________________________________________________ EMPLOYMENT RECORD The U. S. Department of Transportation requires that driver applications show all employment for the past three years. They must also show commercial driver employment for the seven years immediately preceding this three year period. 391.21(b)(10),(11) Current Employer _________________________________ Supervisor’s Full Name ______________________________ Address_________________________________________ Zip ___________________ Phone (___) ________________ Position Held ____________________________________ From _______ To _________ Salary ___________________ Reason for leaving __________________________________________________________________________________ Current Employer _________________________________ Supervisor’s Full Name ______________________________ Address_________________________________________ Zip ___________________ Phone (___) ________________ Position Held ____________________________________ From _______ To _________ Salary ___________________ Reason for leaving __________________________________________________________________________________ (continue on next page) Branscome Paving Co. Application REV. 2015 3 Current Employer _________________________________ Supervisor’s Full Name ______________________________ Address_________________________________________ Zip ___________________ Phone (___) ________________ Position Held ____________________________________ From _______ To _________ Salary ___________________ Reason for leaving __________________________________________________________________________________ APPLICANT MUST READ AND SIGN I authorize you to make such investigation and inquiries of my personal employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other person from all liability in responding to inquiries and releasing information in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules implied, stated, spoken and/or written of Branscome Paving Company. I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purposes of investigating my safety performance history as required by 49 CR391.23(d) and (e). I understand that I have the right to: • review information provided by previous employers; • have errors in the information correct by previous employers and for those previous employers to resend the corrected information to the prospective employer; and • have a rebuttal statement attached to the alleged erroneous information if the previous employer(s) and I cannot agree on the accuracy of the information. I certify that I have read and understood all of this employment application. It is agreed and understood that the employer or his agents may investigate my background to ascertain any and all information of concern to my employment history, whether same is of record or not, and I release employers and other person named herein from all liability of any damages on account of furnishing such information. I understand that, as an applicant for a position with this company, I may be asked to demonstrate that I am capable of performing tasks which are pertinent to the job. I also understand that if offered a job, it may be conditioned on the result of physical examination and drug test. I further certify that I am a genuine applicant for employment and this application is being submitted solely for the purpose of seeking employment with employer and for no other reason. I agree to furnish such additional information and complete such examinations as may be required to complete my employment file This certifies that this application was completed by me, ad that all entries on it and information in it are true and complete to the best of my knowledge. ______________________________ _____________________________________________________________ Date Applicant Signature Branscome Paving Co. Application REV. 2015 4 Branscome Paving Co. Application REV. 2015 5 Branscome Paving Co. Application REV. 2015 6 EMPLOYEE ACKNOWLEDGEMENT, CONSENT, RELEASE AGREEMENT
I have read, or have had read to me, the entire contents of the Safety Program and agree to comply with all
requirements. I have been given an opportunity to ask question and fully understand the meaning of the policy.
Additionally, I understand that I should contact a company supervisor or Safety Officer should I have any further
questions or concerns. By singing below, I have acknowledged having receipt of this policy and consent to agree
to abide by the contents.
Name (print) ________________________________________________
Signature ___________________________________________________
Date
___________________________________________________
DO NOT WRITE BELOW THIS LINE. SPACE INTENDED FOR OFFICE USE ONLY. 
Did applicant provide Driving record? ____________________________________________________________ 
Did applicant, if driving, complete a Motor Vehicle Report Information Request Form (DMV)? _______________ 
Did applicant sign the Employee Acknowledgement and Confirmation Document? ___________________________ 
Did applicant complete the E – Verify process? _____________________________________________________ 
Applicant Hired YES_____________________________ 
Date, department & salary – See Employee Acknowledgment and Confirmation Document. NO ________________________ Branscome Paving Co. Application REV. 2015 7 BRANSCOME PAVING COMPANY
Julius Branscome, Inc.
7812 Bethlehem Road
Manassas Virginia 20109
www.branscomepaving.com
Email kevinshuddleston@branscomepaving.com
Office 703.335.1000
Fax 703.335.5722
Employee Acknowledgment & Confirmation Document
Crew Assignment
Start Date & Time
Starting Pay
/ /201_ @ ___:____ AM/PM
$
Eligible for 401k
1,000 Hours or 1 year of service
Eligible for Health
Insurance
After 90 days of employment
Holiday Pay
Must work the day before & the
day after to receive
Over Time Pay
Anything over 40 hours / week
Sick Pay
N/A
Guarantee Hours
See Immediate Supervisor
Work Week
Sunday through Saturday
Pay Day
Every Tuesday
Safety Is Priority
At All Times Work In A Safe
Manner
I, ___________________ accept and confirm that the information above was clearly discussed and shared
with me. Furthermore, I understand the information above is subject to change.
__________________ __/___/201__
(Employee’s Signature)
Date
Branscome Paving Co. Application REV. 2015 Kevin Huddleston
Human Resource Manager 8