Brakebush Brothers, Inc.

Date of Application______

APPLICANT INFORMATION
Last Name / First / M.l.
Street Address / Apartment/Unit #
City / State / Zip
Phone / E-mail Address
Date Available Social Security #
Position Applied for
Are you authorized to work in the United States? / YES / NO / Are you willing to work required overtime? YES I NO
Are you at least 18 years of age? / YES / NO
Have you been convicted of a felony within the last 7 years? (A conviction will not necessarily bar employment. We will evaluate the circumstances of the offense as to a substantial relationship to the circumstances of the job.)We reserve the right to use information outside the 7 year time frame. / YES / NO / Are you capable of performing the essential functions of the position for which you are applying with or without accommodations? / YES I NO
Have you ever been discharged by an employer? / YES / NO / If yes,
explain
Are you on layoff or subject to recall? / YES / NO
What type of employment are you interested in? Full-Time / Part-Time Shift 1st 2nd 3rd
EDUCATION
High School / Address
From / To IDid you graduate? / YES / NO Degree I
College / Address
From / To IDid you graduate? / YES / NO Degree I
Other / Address
From / To IDid you graduate? / YES / NO Degree I
REFERENCES
Please list three professional references.
Full Name / Relationship
Company / Phone
Address
Full Name / Relationship I
Company / Phone
Address
Full Name / Relationship I
Company / Phone
Address
How did you hear of the job opening? Walkin____ Ad/Newspaper____ Employment Agency_____ Job Fair____
Website____ Internet____ Saw Company/Truck____ Word of Mouth_____ Employee (Name)______
PREVIOUS EMPLOYMENT
Company / Phone
Address / Supervisor
Job Title / !Starting Salary / Ending Salary
Responsibilities
From I / To I !Reason for Leaving
May we contact your previous supervisor for a reference? / YES / NO 0
Company / Phone
Address / Supervisor
Job Title / !Starting Salary / Ending Salary
Responsibilities
From I / To I Reason for Leaving
May we contact your previous supervisor for a reference? / YES / NO
Company / Phone
Address / Supervisor
Job Title / !Starting Salary / Ending Salary
Responsibilities
From I / To I !Reason for Leaving
May we contact your previous supervisor for a reference? / YES / NO

If employed, may we contact your present employer? Yes 0 No 0

Have you filed an application here before? Yes 0 No 0

Have you ever been employed here before? Yes 0 No 0 Dates ______

MILITARY SERVICE

Branch of Service: / Duties:
Describe any specialized training:

READ CAREFULLY

I certify that the answers given by me to the foregoing questions and statements are true and correct without consequential omissions of any kind. I understand that employment is subject to verification of lawful age and legal right to work in the United States. I will submit such documents as may be required to verify the same.

I agree that the company shall not be held liable in any respect if my employment is terminated because of false statements, answers or omissions made by me in this application. I understand that any misleading or incorrect statements may render this application void, and if employed, may cause termination.

I understand that I may be required to take pre-employment job related skills tests.

I understand that this application will be kept on file for six months. After that time period, I must submit another application.

I understand that a placement medical examination based on the requirements of the position for which I am being considered maybe required and that pre-employment drug testing is a requirement. I authorize any physician who has examined me or treated me to give Brakebush Brothers, Inc. or Brakebush Transportation, Inc. a complete report.

I also authorize the companies, schools, law enforcement, driver license agency, Dept. of Justice, Backgrounds online, Hireright or persons named above to give any information requested regarding my employment, character and qualifications. I hereby release from liability and responsibility all persons, companies or corporations supplying such information and Brakebush Brothers, Inc. in obtaining the same.

In the event of employment, I understand that employment can be terminated by either party for any reason with or without notice. I have carefully read the above and fully understand the same.

Any job offers are provisional and contingent upon results of all pre-employment screening.

I certify that this application was completed by me and that all entries on it and information in it are true and complete to the best of my knowledge.

______

Date Signature

9/28/15