EMPLOYMENT APPLICATION
1. Employer Information
Employer: Gary Jackson Heating Services
Address: 152 Davis St #3
City/State/ZIP: Keene, New Hampshire 03431
Telephone: 603-352-6900
It is the policy of Gary Jackson Heating Services to provide equal employment opportunities to all applicants and employees without regard to any legally protected status such as race, color, religion, gender, national origin, age, disability or veteran status.
2. Applicant Information
Applicant Name: ______
Address: ______
City/State/ZIP: ______
Number of years at this address: ______
Daytime phone:______Evening phone: ______
Social Security Number: ______
Driver's License (State/Number): ______
3. Emergency Contact
Who should be contacted if you are involved in an emergency?
Contact Name: ______
Relationship to you: ______
Address: ______
City/State/ZIP: ______
Daytime phone:______Evening phone: ______
4.Job Position Applied For:OIL/GAS/AIR CONDITIONING SERVICE TECHNICIAN
5.Salary Desired: $ ______per ______
6. Who referred you to our company? ______
7.Are you at least 18 years old?______Yes ______No
8. How will you get to work? ______
9. If applicable, are you available to work overtime? _____ Yes _____ No
10. If you are offered employment, when would you be available to begin work?
______
11. Are you legally eligible for employment in the United States? _____ Yes _____ No
12. Are you able to perform the essential functions of the job position with
or without reasonable accommodation?______Yes ______No
What reasonable accommodation, if any, would you require?
______
13. Have you ever been convicted of any crime, including traffic violations?
______Yes ______No If yes, please describe:
______
THE EXISTENCE OF A CRIMINAL RECORD DOES NOT CONSTITUTE AN AUTOMATIC BAR TO EMPLOYMENT UNLESS RELEVANT TO THE TYPE OF EMPLOYMENT.
14. Applicant's Skills
Check those skills that you have. List any other skills that may be useful for the job you are seeking. Enter the number of years of experience, and circle the number which corresponds to your ability for each particular skill. (One represents poor ability, while five represents exceptional ability.)
Ability or
SkillYears of Experience Rating
[ ]Microsoft Office Suite (Word, Excel, etc.) ______1 2 3 4 5
[ ]Customer service ______1 2 3 4 5
[ ]MECHANICAL & ELECTRICAL APTITUDE ______1 2 3 4 5
[ ]KNOWLEDGE OF HVAC PRINCIPLES, PRACTICES,
METHODS, TOOLS & EQUIP ______1 2 3 4 5
[ ]ABILITY TO READ BLUE PRINTS/
SIMPLE DRAWING ______1 2 3 4 5
[ ]ABLE TO WORK FROM COMPLEX
WRITTEN/ORAL INSTRUCTIONS ______1 2 3 4 5
[ ]UNDERSTAND THEORY & PRINCIPALS
OF A/C & REFRIGERATION EQUIPMENT______1 2 3 4 5
[ ]BE ABLE TO PLAN WORK, GET ALONGWITH OTHERS & WORK AS A TEAM MEMBER ______1 2 3 4 5
15. Applicant Employment History
List your current or most recent employment first.
Employer Name: ______
Supervisor Name: ______
Address: ______
City/State/ZIP: ______
Job Duties: ______
Reason for Leaving: ______
Dates of Employment (Month/Year): ______
Employer Name: ______
Supervisor Name: ______
Address: ______
City/State/ZIP: ______
Job Duties: ______
Reason for Leaving: ______
Dates of Employment (Month/Year): ______
Employer Name: ______
Supervisor Name: ______
Address: ______
City/State/ZIP: ______
Job Duties: ______
Reason for Leaving: ______
Dates of Employment (Month/Year): ______
16. Applicant's Education and Training
College/University Name and Address
______
Did you receive a degree?______Yes _____ No If yes, degree received: ______
High School/GED Name and Address
______
Did you receive a degree?______Yes _____ No
______Yes ______No
Other Training (graduate, technical, vocational):
______
Awards, Honors, Special Achievements:
______
Military Service:
______Yes _____ No
Branch: ______
Specialized Training: ______
17. References
List any two people who would be willing to provide a reference for you.
Name: ______
Address: ______
City/State/ZIP: ______
Telephone: ______
Relationship: ______
Name: ______
Address: ______
City/State/ZIP: ______
Telephone: ______
Relationship: ______
18. Please provide any other information that you believe should be considered:
______
______
CERTIFICATION
I certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination.
I authorize Gary Jackson Heating Services to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades. I authorize those persons designated as references to fully and freely communicate information regarding my previous employment and education.
I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO ITS TERMS.
______
APPLICANT SIGNATURE DATE