Employment Application PERSONAL INFORMATIONName First Last PhoneEmail Address Street Address City State / Province / Region AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country ARE YOU A U. S. CITIZEN:YESNOBy signing this employment application you hereby consent to submit to a drug or alcohol test in order to meet Bonneville’s policy regarding the selection of applicants for employment. I further authorize to the release of the results of said tests to Bonneville Asphalt. I understand that it is the current use of illegal drugs that would prohibit me from being employed at this Company.IF SELECTED FOR EMPLOYMENT ARE YOU WILLING TO SUBMIT TO A PRE-EMPLOYMENT DRUG SCREENING TEST:YESNOPOSITIONPOSITION YOUR ARE APPLYING FOR:AVAILABLE START DATE: Depending on the position you are hired to fill Bonneville Asphalt hires for full-time seasonal work. Weather impacts the work we do so we try to work as far into the winter as possible and start up as early in the spring as possible with some on-call work during the winter. We typically work about 9+ months of the year and the available hours are plenty during those months.EMPLOYMENT DESIRED: FULL TIME PART TIME SEASONAL OR TEMPORARY EDUCATIONSCHOOL NAMELOCATIONDATES ATTENDEDDEGREE RECEIVEDMAJOR CURRENT & PREVIOUS 3 YEARS ADDRESSESAddressFROM TO AddressFROM TO AddressFROM TO EMPLOYMENT HISTORYEMPLOYER 1: EMPLOYER: JOB TITLE: DATES EMPLOYED: FROM TO JOB DESCRIPTION:AddressCITYSTATE SUPERVISOR’S NAME & PHONE NUMBER: PAY RATE: EMPLOYER 2: EMPLOYER: JOB TITLE: DATES EMPLOYED: FROM TO JOB DESCRIPTION:AddressCITYSTATE SUPERVISOR’S NAME & PHONE NUMBER: PAY RATE: EMPLOYER 3: EMPLOYER: JOB TITLE: DATES EMPLOYED: FROM TO JOB DESCRIPTION:AddressCITYSTATE SUPERVISOR’S NAME & PHONE NUMBER: PAY RATE: DRIVING EXPERIENCE / CERTIFICATION CLASS OF EQUIPMENT APPROX MILES DATES: FROM TO STRAIGHT TRUCK:TRACTOR & SEMI-TRAILER(S): STICK SHIFT?YESNOOTHER (SPECIFY): In order to be compliant with UDOT our drivers must have a current Medical Examiners Certificate (Medical Card). This requires a physical exam that typically takes place at the same time as the pre-employment drug screening. By signing this employment application you hereby consent to a physical exam for the purpose of obtaining a medical card.MEDICAL CARD EXPIRATION DATE:LIST STATES OPERATED IN, FOR THE LAST FIVE (5) YEARS:LIST SPECIAL COURSES/TRAINING COMPLETED (PTD/DDC,HAZMAT,ETC):LIST ANY SAFE DRIVING AWARDS YOU HOLD AND FROM WHOM:ACCIDENT RECORD FOR THE PAST THREE (3) YEARS:DATE OF ACCIDENTLOCATION OF ACCIDENTNUMBER OF INJURIES TRAFFIC CONVICTION AND FORFEITURES FOR THE LAST THREE (3) YEARS:DATELOCATIONCHARGEPENALTY DRIVER’S LICENSE: LIST EACH DRIVER’S LICENSE HELD IN THE PAST THREE (3) YEARS:STATELICENSETYPEENDORSEMENTSEXPIRATION DATE HAVE YOU EVER BEEN DENIED A LICENSE, PERMIT OR PRIVILEGE TO OPERATE A MOTOR VEHICLE?YESNoIf ‘yes’ explain:HAS ANY LICENSE, PERMIT OR PRIVILEGE EVER BEEN SUSPENDED OR REVOKED?YESNoIf ‘yes’ explain:IS THERE ANY REASON YOU MIGHT BE UNABLE TO PERFORM THE FUNCTIONS OF THE JOB FOR WHICH YOU HAVE APPLIED FOR.YESNoIf ‘yes’ explain:DO YOU HAVE ANY SR22 FILINGS OR OTHER RESTRICITONS?YESNoIf ‘yes’ explain:HAVE YOU EVER BEEN CONVICTED OR A FELONY?YESNoIf ‘yes’ explain:I CERTIFY THAT MY ANSWERS ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. IF THIS APPLICATIN LEADS TO EMPLOYMENT, I UNDERSTAND THAT FALSE OR MISLEADING INFORMATION IN MY APPLICATION OR INTERVIEW MAY RESULT IN TERMINATION OF MY EMPLOYMENTName First Last Date By submitting this application you are agreening to the terms herein and validity of your information you have provided. This iframe contains the logic required to handle Ajax powered Gravity Forms.