Applicant Information Name * First Name Last Name Date of birth * MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * What position are you interested in? CCTV Technician Vac Truck Operator Do you have a valid drivers license? Yes No Drivers License Number Are you a citizen of the United States? Yes No Have you ever worked for this company? Yes No Have you ever been convicted of a felony? Yes No If so explain EDUCATION High School & high school address Did you graduate? Yes No Graduation Date MM DD YYYY College & College Address Did you graduate? Yes No Graduation Date MM DD YYYY Refrences Full name First Name Last Name Company Position Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Reference #2 Full Name First Name Last Name Company Position Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Reference #3 Full Name First Name Last Name Company Position Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Military Service Did you serve in the military? If no leave blank Yes No Branch From MM DD YYYY To MM DD YYYY Rank at discharge Type of discharge Disclaimer & Agreement US Utility Potholing & Air Excavation provides equal opportunity in all of our employment practices to all qualified employees and applicants without regard to race, color, religion, gender, national origin, age, disability, marital status, military status or any other category protected by federal, state and local laws. This policy applies to all aspects of the employment relationship, including recruitment, hiring, compensation, promotion, transfer, disciplinary action, layoff, return from layoff, training and social, and recreational programs. All such employment decisions will be made without unlawfully discriminating on any prohibited basis. US Utility Potholing & Air Excavation is a Drug free work place. On acceptance of application employee will be asked to consent to a Drug test before hiring. I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. I agree Thank you! Job Application
