Job Application

PERSONAL INFORMATION

Name*

First Last

SSN*

Date*

Physical Address*

Street Address Address Line 2 City State ZIP Code

Mailing address same as physical?*

Yes
No

Mailing Address

Street Address Address Line 2 City State ZIP Code

Cell Phone*

Home Phone

Email*

Date of Birth, Felony, and Misdemeanor information is for driver and machine operator insurance requirements. Foreign language can help with communication with employees and customers, especially Spanish.

Date of Birth*

Foreign Languages?

Are you prevented from lawfully becoming employed in the U.S.?*

No
Yes

Have you been convicted of a felony or misdemeanor within the last 5 years?*

No
Yes

EMPLOYMENT DESIRED

Position

Start Date Availability

Salary Desired

Which region are you interested in?*

Are you currently employed?*

Yes
No

If so, may we inquire of your present employer?

Yes
No

Where and when?

Have you applied with Twin Enviro before?

Yes
No

Education

High School Name*

High School Location*

Graduate?*

Yes
No

Number of years attended?

College Name*

College Location*

College Graduate?*

Yes
No

Number of years attended?

Subject or Major?

Trade School/ Training

Location

Date attended?

Graduate

Yes
No

FORMER EMPLOYERS (List your last four employers starting with the last one first)

1: Employer Name

First Last

Dates Employed (Start/End MM/YYYY)

Employer Address

Street Address Address Line 2 City State ZIP Code

Salary

Position

Reason for Leaving

2: Employer Name

First Last

Dates Employed (Start/End MM/YYYY)

Employer Address

Street Address Address Line 2 City State ZIP Code

Salary

Position

Reason for Leaving

3: Employer Name

First Last

Dates Employed (Start/End MM/YYYY)

Employer Address

Street Address Address Line 2 City State ZIP Code

Salary

Position

Reason for Leaving

4: Employer Name

First Last

Dates Employed (Start/End MM/YYYY)

Employer Address

Street Address Address Line 2 City State ZIP Code

Salary

Position

Reason for Leaving

JOB REFERENCES (Supervisor preferred)

1: Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Business Name

Phone

Email

2: Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Business Name

Phone

Email

3: Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Business Name

Phone

Email

PHYSICAL RECORD—DO YOU HAVE ANY PHYSICAL LIMITATIONS FOR PERFORMING WORK HERE?

Lifting?

Yes
No

Back Injury?

Yes
No

Prior Workers Comp Claim?

Yes
No

Signature

I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND UNDERSTAND THAT, IF EMPLOYED, FALSIFIED STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS FOR DISMISSAL. I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY HAVE, PERSONAL OR OTHERWISE AND RELEASE ALL PARTIES FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM FURNISHING SAME TO YOU. I UNDERSTAND AND AGREE THAT, IF HIRED, MY EMPLOYMENT IS FOR NO DEFINE PERIOD AND MAY, REGARDLESS OF THE DATE OF PAYMENT OF MY WAGES AND SALARY, BE TERMINATED AT ANY TIME WITHOUT ANY PRIOR NOTICE.

Date

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Routt & Moffat County

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