Application for Employment

A.H. Beck Foundation Company, Inc. and affiliates (“Company”) are an Equal Opportunity and Affirmative Action Employer and will consider all applicants for all positions equally without regard to their race, sex, sexual orientation, gender identity, age, color, religion, national origin, veteran status, genetic information, disability, or for any other characteristic protected by Federal or State Laws.

GENERAL INFORMATION

Position(s) Applied for*

Date of Application*

Referral's Full Name*

Date Available for Work*

Availability:* Full-Time Part-Time Shift Work Temporary

PERSONAL INFORMATION

First Name* Last Name* Middle Name* Street Address* City* State and Zip Code* Daytime Phone No.* Alternate Phone No. E-mail Address*

EDUCATION

HIGH SCHOOL

Name and Location of School No. of Years Completed Did you Graduate? Yes No Degree or Diploma

COLLEGE

Name and Location of School No. of Years Completed Did you Graduate? Yes No Degree or Diploma

BUSINESS / TECHNICAL

Name and Location of School No. of Years Completed Did you Graduate? Yes No Degree or Diploma

Are you attending School now?* Yes No

Name/Course of Study:

SPECIAL SKILLS

Do you have any other specialized training, apprenticeship, skills, which you feel, makes you especially suited for the position applied for? If yes, please explain.

LICENSES / CERTIFICATIONS

Do you currently hold any of the following licenses/certifications? CDL-A CDL-B CLASS C Other

If Other, provide licenses / certifications

If yes, provide license/registration numbers and issuing state:

Do you currently hold a TWIC card? Yes No

REFERENCES

Please provide the names of 3 personal references (not family members or employers) who have known you for at least 3 years

Name Address Phone No.

EMPLOYMENT HISTORY

Have you ever been terminated from employment or asked to resign by any employer? Yes No

If yes, please provide name, dates, and circumstances.

MILITARY SERVICE

Have you served in the U.S. Armed Forces? Yes No

If Yes, in what "Branch"

Describe any military training received relevant to the position which you are applying

EMPLOYMENT EXPERIENCE 1

Employer* Dates of Employment From:* Dates of Employment To:* Address* Telephone No.* Supervisor* Telephone No.* Job Title* Starting Salary* Ending Salary* Work Performed / Job Duties* Reason for Leaving*

EMPLOYMENT EXPERIENCE 2

Employer Dates of Employment From: Dates of Employment To: Address Telephone No. Supervisor Telephone No. Job Title Starting Salary Ending Salary Work Performed / Job Duties Reason for Leaving

EMPLOYMENT EXPERIENCE 3

Employer Dates of Employment From: Dates of Employment To: Address Telephone No. Supervisor Telephone No. Job Title Starting Salary Ending Salary Work Performed / Job Duties Reason for Leaving

EMPLOYMENT EXPERIENCE 4

Employer Dates of Employment From: Dates of Employment To: Address Telephone No. Supervisor Telephone No. Job Title Starting Salary Ending Salary Work Performed / Job Duties Reason for Leaving

APPLICANT VERIFICATION

I verify that all the information on this application and in exhibits and resumes submitted to the Company is true, correct and complete. I have not withheld any information requested by the Company. I understand that false, misleading, incomplete or omitted information will result in rejection of my application or termination of employment, whenever discovered.

I authorize the Company and its agents to confirm all information provided on this application, exhibits and resumes and to investigate my suitability for employment. I release the Company and all persons and organizations from any claims, liabilities or damages from obtaining or furnishing information about me. I understand that the Company will provide me a separate disclosure and authorization if it desires to conduct a consumer report for employment purposed under the Fair Credit Reporting Act.

I understand that this application is not a job offer or employment contract for any specific time period. If hired, my employment will be for an indefinite time period and I may resign or be released at any time without notice or requirement of cause.

I understand that if employed, I will be required to complete a federal I-9 form and provide verification of my identity and right to work in the United States and its territories.

Any conditional offer of employment is subject to successful completion of all employment requirements, include but not limited to successful completion of a medical examination, verifying employment/personal references, and verifying criminal record and driving records (where appropriate).

Because of the Company’s safety concerns for all positions, and federal requirements for some positions, all final applicants given a conditional employment offer will be requested to submit to testing for the current illegal use of drugs (“controlled substances”) as defined by the Company’s Substance Abuse Policy. The drug test will only be performed with the written consent of the final applicant. Applicants who decline to consent or submit to testing for the current illegal use of drugs, or who produce a “positive test result,” will not be further considered for employment.

If employed, I will company with Company policies, rules and procedures.

Type Your Name to Sign*

Today's Date*

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Application for Employment

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