Job-Form

Employment Application

Corporate Headquarters
124 East Main Street
Riverton, Wyoming 82501
 
INBERG-MILLER ENGINEERS is an at-will employer and retains the
absolute right to terminate me, at any time, with or without good cause
 

1. Please read "APPLICANT NOTE" below.
2. Complete both pages.
3. If more space is needed to complete any
question, use comments section at the
bottom of this page.
4. PLEASE NOTE "NOT APPLICABLE" IF NOT
ANSWERING A QUESTION
NAME:
E-mail:
HOME PHONE: WORK PHONE:
CURRENT ADDRESS:
PRIOR ADDRESS:

This application form is intended for use in evaluating your qualifications for employment. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment, terminating employment. All qualified applicants will receive consideration without discrimination because of sex, marital status, race, color, age, creed, national origin, sexual orientation, military reserve membership, ancestry, religion, height, weight, use of a guide or support animal because of blindness, deafness or physical handicap, or the presence of disabilities. A felony conviction will not necessarily bar an applicant from employment. Additional testing of job-related skills and for the presence of drugs in your body may be required prior to employment. After an offer of employment, and prior to reporting to work, you may be required to submit to a medical review. Depending on company policy and the needs of the job, you will be required to complete a medical history form and may be examined by a medical professional designated by the company.

For which position are you applying?
What date can you start? What category would you prefer?
For which schedule are you available*:
Weekdays Weekends Nights Overtime Holiday
reasonable efforts will be made to accommodate religious beliefs and practices
Yes No If the job requires, do you have the appropriate valid drivers license?
 
Name on license DL# Type State of issue
Yes No Have you had any moving violations? Please describe
  Please list any other skills, licenses or certificates that may be job-related or that you feel would be of value to this job or company.
 
Yes No Have you been given a job description or had the essential functions of the job explained to you?
Yes No Do you understand these essential functions?
Yes No Can you perform the essential functions of this job with or without reasonable accommodation?
  List languages in which you are fluent
  List states and counties of residence for the past seven years.
Yes No o Have you used any names other than given above? If so, please list in comments, below
Yes No Have you been convicted of a crime in the past seven years? If so, please describe in the boxes below
(Conviction will not necessarily be a bar to employment. In accordance with company policy and applicable state and federal laws, factors such as
age at time of the offense, remoteness of the offense, time since last conviction, nature of the job sought and rehabilitation effort will be reviewed.)
PLEASE NOTE. Your application will not be considered unless every question in this section is answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are critical .
MOST RECENT EMPLOYER Yes No Are you currently working for this employer?
  Yes No If yes, may we contact?
COMPANY NAME CITY STATE Phone
FROM: TO:
    JOB TITLE SUPERVISOR NAME
DATES EMPLOYED
DUTIES
$ PER
SALARY (HOUR, WEEK, MONTH REASON FOR LEAVING

SECOND MOST RECENT EMPLOYER

COMPANY NAME CITY STATE Phone
FROM: TO:
DATES EMPLOYED
DUTIES
$ PER
SALARY (HOUR, WEEK, MONTH REASON FOR LEAVING

THIRD MOST RECENT EMPLOYER

COMPANY NAME CITY STATE Phone
FROM: TO:
    JOB TITLE SUPERVISOR NAME
DUTIES
$ PER
SALARY (HOUR, WEEK, MONTH) REASON FOR LEAVING
Include only individuals familiar with your work ability. Do not include relatives.
NAME ADDRESS/PHONE YEARS KNOWN/RELATIONSHIP
NOTE: do not fill out any part of this section you believe to be non-job related.
  Please list highest grade completed.
If your school records are under a different name than listed on page 1, please enter that name:
NAME CITY/STATE GRADUATE? DEGREE?
ertify that I have read and understand the applicant note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts called for in this application, whether on this document or not, may result in rejections of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any of this information. I authorize all former employers, persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.
SIGNATURE DATE