In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color , religion, sex,national origin, age marital status, veteran status, non-job related disability, ir any other protected group status.

Date

I am applying for:

DRIVER
HELPER
MECHANIC
ADMIN

Name

First

Middle

Last

Phone

Current Address

Address Line 1

Address Line 2

City

State

Zip Code

Do you have the legal right to work in the United States?

Social Security No:

Birthdate

License No.

State

Expires

Have you ever been employed by Unity Disposal or affiliated Company?

When?

Are you currently employed by another company?

When was you last haul?

How did you hear about Unity Disposal & Recycling?

Who referred you?

Conviction of a crime is NOT an automatic bar to employment, all circumstances will be considered. Have you ever been convicted of a felony?

You answered yes to the question above. Please explain.

Is there any reason you might be unable to perfom the functions of the job for which you are appling for?

Please explain your , Yes.

EMPLOYMENT HISTORY

List employers in reverse order starting with the most recent

Employer Name

Position Held

Date

Address

Address Line 1

Address Line 2

City

State

Zip Code

Contact Person

Salary Wage

Reason for leaving

Do you have an additional employment that you want to enter?

2nd Employer Name

Position Held

Date

Address

Address Line 1

Address Line 2

City

State

Zip Code

Contact Person

Phone

Salary Wage

Reason for leaving

Do you have a 3rd employment that you want to enter?

3rd Employer Name

Position Held

Date

Address

Address Line 1

Address Line 2

City

State

Zip Code

Contact Person

Phone

Salary Wage

Reason for leaving

Professional References:

1st Professional Reference

Company Name

Contact Person

Phone

2nd Professional Reference

Company Name

Contact Person

Phone

3rd Professional Reference

Company Name

Contact Person

Phone

Personal References:

1st Personal Reference

Name

Relationship

Phone

2nd Personal Reference

Name

Relationship

Phone

3rd Personal Reference

Name

Relationship

Phone

EDUCATION

Highest Grade completed

High School

College

Last School Attended

City

State

Drivers/Fit For Duty Exam

Have you ever been denied a license, permit or privilege? to operate a motor vehicle

Has any license, permit or privilege been suspended or revoked?

Has you been involved in a DOT Accident where there was an injury or fatality?

Do you hold a valid DOT Medical Card?

Expiration Date?

Have you ever been injured on the job ?

How long were you out of work?

Can you push and lift 75lbs?

Please give us details about you weight lifting or pushing.

This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge.

In the event of employment, I understand that false or misleading information given in my application or interview(s) mat result in immediate discharge, I understand, also that I am required to abide bu all the rules of Unity Disposal and Recycling.

Date

Signature