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Scott’s Painting & Staining Inc.
18230 Tammy Trail
Omaha, NE 68135
(402) 894-9001
(Please print clearly)
Application for position as: ______________________ Date:
__________________
First Name: ___________________________________ Social Security #:
____________________
Middle Name: _________________________________ Home Phone #: (
)_________________
Last Name: ___________________________________ Other Phone #: (
)__________________
Address:
________________________________________________________________________
City: ____________________________ State:_________________
Zip: ______________
Are you authorized to work in the United States? _____________
Are you currently on layoff or leave from another company? ____
Date able to start: ______________________________________
Pay expected: _________________________________________
Are you available to work full time? _______________________
How many hours per week? ______
Are you able to work overtime if required? __________________
List time available during week and weekend:
_______________________________________________
Have you ever been convicted of, OR pled guilty to a felony? (Excluding
misdemeanors and traffic offenses.) _________
If yes, explain:
______________________________________________________
_________________________________________________________________
School : Name/Location of School
: Course of Study : Years
: Graduate? : Completed
High School _________________________
_________ ________ _______
______
Business, Trade, Tech _________________ _________ ________ _______ ______
College ____________________________ _________ ________ _______ ______
Professional Registrations/Licenses Held:
____________________________________________________
Special Qualifications/Skills:
______________________________________________________________
Job-Related Activities that may benefit your work:
_____________________________________________
Are you able to work outdoors? _____________________
Do you have problems with heights up to 40 feet on extension ladders?
_______________
Please list any special abilities or knowledge, which you have that are related
to the job for which you are applying.
______________________________________________________________________________________
______________________________________________________________________________________
In addition to the work experience described in this application, what other
experiences skills or abilities do you have that should be considered in
evaluating your qualifications for this job?
___________________________________________________________________________________________________________
Employment History Please list most recent first. This section may be skipped if
duplicated in your resume.
Company Name: _____________________________________ Phone:
_________________
Name of Supervisor: __________________________________
May we contact this employer? _____ If not, please
explain: ___________________________________
Address: ______________________________________________________
City: ___________________________ State:
_______________ Zip: ___________________
Job Duties:
___________________________________________________________________________
Reason for leaving:
_____________________________________________________________________
Starting Position: __________________________ Ending
Position: ____________________________
Dates of employment: ______________________ Pay Rate:
__________________________________
Company Name: _____________________________________ Phone:
_________________
Name of Supervisor: __________________________________
May we contact this employer? _____ If not, please
explain: ___________________________________
Address: ______________________________________________________
City: ___________________________ State:
_______________ Zip: ___________________
Job Duties:
___________________________________________________________________________
Reason for leaving:
_____________________________________________________________________
Starting Position: __________________________ Ending
Position: ____________________________
Dates of employment: ______________________ Pay Rate:
__________________________________
Company Name: _____________________________________ Phone:
_________________
Name of Supervisor: __________________________________
May we contact this employer? _____ If not, please
explain: ___________________________________
Address: ______________________________________________________
City: ___________________________ State:
_______________ Zip: ___________________
Job Duties:
___________________________________________________________________________
Reason for leaving:
_____________________________________________________________________
Starting Position: __________________________ Ending
Position: ____________________________
Dates of employment: ______________________ Pay Rate:
__________________________________
Company Name: _____________________________________ Phone:
_________________
Name of Supervisor: __________________________________
May we contact this employer? _____ If not, please
explain: ___________________________________
Address: ______________________________________________________
City: ___________________________ State:
_______________ Zip: ___________________
Job Duties:
___________________________________________________________________________
Reason for leaving:
_____________________________________________________________________
Starting Position: __________________________ Ending
Position: ____________________________
Dates of employment: ______________________ Pay Rate:
__________________________________
Additional References / Job sites / Homes Painted
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
PLEASE READ THE FOLLOWING AND SIGN BELOW
I declare that I am qualified to perform all the duties of the position I am
seeking. I also declare that the information I have provided on this application
is correct and that any false statements or omissions will justify my rejection
or dismissal. I authorize the company to contact any of my previous employers as
well as any reference source to verify the facts and information that I have
furnished regarding information provided on this application, on my resume, or
during my interview. I authorize any person(s) having knowledge to provide such
information to the company, and release from liability and agree to hold
harmless any person that furnishes such information in good faith, as allowed by
applicable state and federal laws. I will agree to a drug test, if permitted by
law, to be paid for by the company. Should I become involved in a claim for
worker’s compensation or any other litigation after employment by the company, I
will allow the company to supply my employment records (as allowed by applicable
state and federal laws) to an opposing party. If employed by the company, I
understand that I will be an employee at will and that my employment with
Scott’s Painting & Staining Inc., may be terminated at anytime by myself or
Scott’s Painting & Staining Inc. for any reason whatsoever. Should I become
employed by Scott’s Painting & Staining Inc., I authorize Scott’s Painting &
Staining Inc. to conduct any additional background checks should they become
necessary at any point during my employment. I also understand that this is only
an application for employment an neither an offer of or a contract of employment
and no part of this application must be signed in order for you to be considered
for employment with Scott’s Painting & Staining Inc. By signing the Agreement to
Arbitrate, I understand that the employment at will relationship will not be
altered.
______________________________________________________________________________________
Signature of Applicant
______________________
Date