Employment Application

Are you at least 18 years of age? *
YesNo

First Name *  

Middle Name  

Last Name *  

Address *  

City *  

State *   AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code *  

Phone Number *  

Alternate Phone Number  

Your Email *

If an offer is made, will you be able to show proof of eligibility to work under the citizenship and immigration laws? *
YesNo

Position applying for: *
Laborer     Equipment Operator     Equipment Repair & Maint.     Driver     AdministrativeOther

Have you previously filed an application with Affordable Paving? *
YesNo
If yes, when and what position?  

If an offer is made, when can you start?  

Hours you are able to work: *   Temp     Part-Time     Full-Time     Saturdays

Have you ever been convicted or placed on probation for a felony? *
YesNo
If you answered “Yes,” please give details:  

High School Name:  

High School Address:  

Achieved GED? *
YesNo

Start Date  

End Date  

College School Name:  

College School Address:  

Achieved Degree?
YesNo
Type of Degree:  

Start Date  

End Date  

Other School Name:  

Other School Address:  

Achieved Degree?
YesNo
Type of Degree:  

Start Date  

End Date  

List any experience or skills that you feel qualify you for the position(s) that you are seeking:

If presently employed, why are you seeking other employment?

Provide the following information on your current and past employers for the last 5 years. Explain any gaps in employment in the comment section below.

Employer Name:  

Employer Address:  

Title/Position Held:  

Start Date  

End Date  

Ending Salary:  

Key Responsibilities:  

Reason for Leaving:  

Supervisor's Name:  

Supervisor's Phone Number  

Employer 2 Name:  

Employer 2 Address:  

Title/Position Held 2:  

Start Date 2  

End Date 2  

Ending Salary 2:  

Key Responsibilities 2:  

Reason for Leaving 2:  

Supervisor 2's Name:  

Supervisor 2's Phone Number  

Employer 3 Name:  

Employer 3 Address:  

Title/Position Held 3:  

Start Date 3  

End Date 3  

Ending Salary 3:  

Key Responsibilities 3:  

Reason for Leaving 3:  

Supervisor 3's Name:  

Supervisor 3's Phone Number  

Please explain any gaps in employment:

Please provide three work references that are not relatives. If no work references are available, list three school or personal references that are not relatives.

Referral 1 Name:  

Referral 1 Title/Position:  

Referral 1's Phone Number  

Referral 1 Years Known:  

Referral 2 Name:  

Referral 2 Title/Position:  

Referral 2's Phone Number  

Referral 2 Years Known:  

Referral 3 Name:  

Referral 3 Title/Position:  

Referral 3's Phone Number  

Referral 3 Years Known:  

Field and equipment positions at Affordable Paving have physical requirements as follows. If you are applying for one of these positions, please answer the following questions.

Are you able to lift 90 pounds up to 10 times per day, with or without accommodation? *
YesNo

Can you bend, stretch, reach, climb and stand throughout an 8-10 hour period, with or without accommodation? *
YesNo

If driving or operating equipment, can you sit for extended periods of time and climb in and out of a cab, with or without accommodation? *
YesNo

Can you work outside in variable as well as extreme hot and/or cold working conditions, with or without accommodation? *
YesNo

I understand that if I am offered employment with Affordable Paving a drug screen for illegal / controlled substances may be required.
I further authorize schools, references, former employers, and physicians or other medical practitioners to provide my record, reason for leaving employment, and all other job-related information they may have concerning me to the Company, and I release and hold harmless all parties providing job-related information from any and all liability or claims for damages that may result from this job-related information’s release, disclosure and use. I understand that unfavorable information Affordable Paving discovers as a result of this investigation may prevent my being hired, or if hired, may subject me to immediate dismissal.

I certify that the information contained in this application is correct to the best of my knowledge and understanding. I agree to conform to the Company’s rules and regulations, and as an at-will employee my employment and compensation can be terminated at any time with or without notice by either the Company or me.

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

Your Full Name (Digital Signature) *  

Sign Date  

File