Prime – Electrical Application Form

EQUAL OPPORTUNITY EMPLOYER. It is our policy to abide by all Federal and State laws prohibiting employment discrimination solely on the basis of a person’s race, color, creed, national origin, religion, age (over), sex, marital status, or physical or mental disability, except where a reasonable, bona fide occupational qualification exists.
Date*
Date Format: MM slash DD slash YYYY
Name*
First Name Last Name
Email*
SOCIAL SECURITY #*
Address City State ZIP Code
HOME PHONE #*
EMERGENCY PHONE #*
CELL PHONE #*
POSITION FOR WHICH YOU ARE APPLYING?
Job Type
- TEMPORARY
- FULL TIME
- PART TIME
Days and times available

Education SCHOOL NAME/ADDRESS DEGREE/MAJOR COURSE OF STUDY
ELECTRICAL LICENSE?
- Yes
- No
TYPE, LICENSE # AND EXP. DATE
DO YOU HAVE TRANSPORTATION TO AND FROM THE JOBSITE, IN OR OUT OF TOWN?
- Yes
- No
LIST ANY OTHER EDUCATION, TRAINING, SPECIAL SKILLS OR CERTIFICATES/LICENSES THAT YOU POSSESS RELATED TO THIS JOB.
LIST ANY MACHINES OR EQUIPMENT ON WHICH YOU ARE QUALIFIED AND EXPERIENCED IN OPERATING.
LIST ANY LANGUAGES THAT YOU FLUENTLY:
Language Speak Read Write
LIST ANY OFFICE SKILLS THAT YOU HAVE, INCLUDING ANY SOFTWARE THAT YOU HAVE WORKED WITH.
DO YOU HAVE A CURRENT PASSPORT?
- Yes
- No
WHAT IS THE EXPIRATION DATE?
Date Format: MM slash DD slash YYYY
DO YOU HAVE A CURRENT TWIC Card?
- Yes
- No
WHAT IS THE EXPIRATION DATE?
Date Format: MM slash DD slash YYYY
ARE YOU 16 YEARS OF AGE OR OLDER?
- Yes
- No
Age
WERE YOU PREVIOUSLY EMPLOYED BY PRIME ELECTRICAL?
- Yes
- No
When?
Please add LIST ANY RELATIVES WORKING FOR PRIME ELECTRICAL.
HAVE YOU EVER BEEN CONVICTED OF ANY CRIMINAL OFFENSE (MISDEMEANOR OR FELONY)
- Yes
- No
LIST YEAR, CHARGE AND OUTCOME OF EACH OFFENSE
HAVE YOU EVER PLED GUILTY OR NOLO CONTENDRE (NO CONTEST) TO A CRIMINAL CHARGE IN ORDER TO QUALIFY FOR DEFFERED AJUDICATION?
- Yes
- No
EXPLAIN
HAVE YOU EVER BEEN ON ANY TYPE OF PROBATION AS A RESULT OF A CRIMINAL CHARGE?
- Yes
- No
LIST
IF YOU ARE CURRENTLY CHARGED WITH A CRIMINAL OFFENSE AND AWAITING TRIAL PLEASE EXPLAIN:
HAVE YOU EVER BEEN CHARGED WITH DWI OR DUI?
- Yes
- No
LIST

LIST ALL WORK EXPERIENCE BEGINNING WITH THE PRESENT OR MOST RECENT JOB. ONE CURRENT OR MOST RECENT JOB IS REQUIRED.
From*
Date Format: MM slash DD slash YYYY
To*
Date Format: MM slash DD slash YYYY
NAME OF EMPLOYER*
TYPE OF BUSINESS*
ADDRESS*
CITY/STATE/ZIP*
TELEPHONE #*
NAME OF SUPERVISOR*
MAY WE CONTACT?*
- Yes
- No
EMPLOYED*
- Yes
- No
YOUR TITLE*
DUTIES*
REASON FOR LEAVING*
LAST SALARY*
From
Date Format: MM slash DD slash YYYY
To
Date Format: MM slash DD slash YYYY
NAME OF EMPLOYER
TYPE OF BUSINESS
ADDRESS
CITY/STATE/ZIP
TELEPHONE #
NAME OF SUPERVISOR
MAY WE CONTACT?
- Yes
- No
EMPLOYED
- Yes
- No
YOUR TITLE
DUTIES
REASON FOR LEAVING
LAST SALARY
From
Date Format: MM slash DD slash YYYY
To
Date Format: MM slash DD slash YYYY
NAME OF EMPLOYER
TYPE OF BUSINESS
ADDRESS
CITY/STATE/ZIP
TELEPHONE #
NAME OF SUPERVISOR
MAY WE CONTACT?
- Yes
- No
EMPLOYED
- Yes
- No
YOUR TITLE
DUTIES
REASON FOR LEAVING
LAST SALARY
From
Date Format: MM slash DD slash YYYY
To
Date Format: MM slash DD slash YYYY
NAME OF EMPLOYER
TYPE OF BUSINESS
ADDRESS
CITY/STATE/ZIP
TELEPHONE #
NAME OF SUPERVISOR
MAY WE CONTACT?
- Yes
- No
EMPLOYED
- Yes
- No
YOUR TITLE
DUTIES
REASON FOR LEAVING
LAST SALARY
LIST THREE PEOPLE WHO ARE NOT EMPLOYERS OR RELATIVES THAT HAVE KNOWN YOU FOR AT LEAST THREE YEARS.
NAME AND ADDRESS OCCUPATION PHONE #
PLEASE INCLUDE ANY OTHER INFORMATION YOU THINK WOULD BE HELPFUL TO US IN CONSIDERING YOU FOR EMPLOYMENT, SUCH AS ADDITIONAL WORK EXPERIENCE, ARTICLES/ BOOKS PUBLISHED, ACTIVITIES, HONORS RECEIVED, ETC. (YOU MAY OMIT ALL INFORMATION THAT WOULD INDICATE AGE, SEX, RACE, RELIGION, COLOR, NATIONAL ORIGIN, OR HANDICAP).

AGREEMENT*
PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY.
I HEREBY AFFIRM THAT THE INFORMATION PROVIDED ON THIS APPLICATION – AND ACCOMPANYING
RESUME, IF ANY – IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I ALSO AGREE THAT
FALSIFIED INFORMATION OR SIGNIFICANT OMISSIONS MAY DISQUALIFY ME FROM FURTHER
CONSIDERATION FOR EMPLOYMENT AND MAY BE CONSIDERED JUSTICIATION FOR DISMISSAL IF
DISCOVERED AT A LATER DATE.
I AUTHORIZE ALL PERSONS LISTED ABOVE – AND ON THE ACCOMPANYING RESUME, IF ANY – TO PRIME
ELECTRICAL GIVE ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT, EDUCATION,
AND ANY OTHER PERTINENT INFORMATION THEY MAY HAVE – PERSONAL OR OTHERWISE. I RELEASE
ALL PARTIES, SUCH PERSONS, AND PRIME ELECTRICAL FROM LIABILITY FOR ANY DAMAGE THAT MAY
RESULT FROM FURNISHING SAME TO PRIME ELECTRICAL.
I UNDERSTAND THAT PRIME ELECTRICAL WILL PROVIDE WORKERS’ COMPENSATION INSURANCE FOR
ITS EMPLOYEES. IN THE EVENT OF ANY INJURY IN THE WORKPLACE, I AGREE THAT MY SOLE REMEDY
LIES IN COVERAGE UNDER PRIME ELECTRICAL WORKERS’ COMPENSATION INSURANCE POLICY.
I UNDERSTAND AND AGREE THAT I MAY BE REQUIRED TO TAKE A DRUG AND ALCOHOL SCREENING
TEST. I HEREBY GIVE MY VOLUNTARY CONSENT FOR A BLOOD AND/OR URINE SAMPLE TO BE
COLLECTED FROM ME AND SUBMITTED FOR TESTING. I ALSO CONSENT TO THE RELEASE OF THE TEST
RESULTS TO PRIME ELECTRICAL FOR ITS USE. I UNDERSTAND ANY POSITIVE DRUG OR ALCOHOL
RESULT MAY PRECLUDE MY EMPLOYMENT.
Applicant Signature*
Date*
Date Format: MM slash DD slash YYYY
Printed name*

Application new form

Prime Electrical

Step 1 of 4

Education	SCHOOL NAME/ADDRESS	DEGREE/MAJOR COURSE OF STUDY

Language	Speak	Read	Write

NAME AND ADDRESS	OCCUPATION	PHONE #