Crossroads Repair

Fields marked (*) are required.

1. Date 5/20/2012

Personal Information

1. First name *
2. Last name *
3. Birth date (mm/dd/yyyy) *
4. Address *
5. City *
6. State * Please select your state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington State West Virginia Wisconsin Wyoming
7. ZIP code *
8. E-mail *
9. Phone (with area code) *
10. Preferred method of contact

    Email Phone
11. Do you have a current driver’s license? *

    Yes No
    1. License class
12. Are you legally eligible to work in the United States? *

    Yes No
    • NOTE: Proof of eligibility will be required upon employment.
13. Have you ever worked for this company? *

    Yes No
    1. If so, when?
14. Have you ever been convicted of a felony? *

    Yes No
    1. If yes, explain

General Information

1. Position for which you are applying *
2. Date you can start (mm/dd/yyyy) *
3. Salary/wage you are seeking *
4. Which work schedule are you willing to accept? *

   Full-time Part-time Temporary

Education and Training

1. What is the highest level of education you have completed? *

   High school GED College Graduate school

   High School Information

   1. Name of high school
   2. What is the highest grade level you completed in high school?

      7 8 9 10 11 12

   College Information

   1. Name of college
   2. Course of study
   3. What is the highest grade level you completed in college?

      Freshman Sophomore Junior Senior
   4. Degree, certificate, occupational license awarded
   5. Subjects of special study or reseach work

   Graduate School Information

   1. Name of graduate school
   2. Course of study
   3. Degree, certificate, occupational license awarded
   4. Subjects of special study or reseach work
2. Special skills, abilities, certificates, licenses, equipment, and/or software operated *
3. List any other qualifications which should be considered *

Military History

1. Are you a military veteran? *

   Yes No
   1. If yes, in what branch?
   2. From (mm/dd/yyyy)
   3. To (mm/dd/yyyy)

Work History

Please complete this section beginning with your present or most recent job.

1. Are you currently employed? *

   Yes No
   1. If yes, may we contact your employer?

      Yes No

Current/Most Recent Employer

1. Name *
2. City *
3. State * Please select your state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington State West Virginia Wisconsin Wyoming
4. Job title *
5. Hours worked per week *
6. What specific tasks did you complete for this job? *
7. What machines/equipment did you operate for this job? *
8. Date started *
9. Date ended *
10. Wage (per hour or pay period) *
11. Reason for leaving *
12. Have you had any other previous employers? *

    Yes No
13. How many other previous employers have you had?

    One Two More than two

    Previous Employer 01

    1. Name
    2. City
    3. State Please select your state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington State West Virginia Wisconsin Wyoming
    4. Job title
    5. Hours worked per week
    6. What specific tasks did you complete for this job?
    7. What machines/equipment did you operate for this job?
    8. Date started
    9. Date ended
    10. Wage (per hour or pay period)
    11. Reason for Leaving

    Previous Employer 02

    1. Name
    2. City
    3. State Please select your state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington State West Virginia Wisconsin Wyoming
    4. Job title
    5. Hours worked per week
    6. What specific tasks did you complete for this job?
    7. What machines/equipment did you operate for this job?
    8. Date started
    9. Date ended
    10. Wage (per hour or pay period)
    11. Reason for Leaving

    Other Previous Employers

    1. Please summarize any other work history you have

References

Please list three individuals who are not related to you and who are not previous employers.

Reference 01

1. First name *
2. Last name *
3. Address *
4. City *
5. State * Please select your state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington State West Virginia Wisconsin Wyoming
6. ZIP code *
7. Phone (with area code) *

Reference 02

1. First name *
2. Last name *
3. Address *
4. City *
5. State * Please select your state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington State West Virginia Wisconsin Wyoming
6. ZIP code *
7. Phone (with area code) *

Reference 03

1. First name *
2. Last name *
3. Address *
4. City *
5. State * Please select your state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington State West Virginia Wisconsin Wyoming
6. ZIP code *
7. Phone (with area code) *

1. Additional comments

Agreement

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 also authorize Crossroads Repair, LLC to make any investigation of my personal or employment history, and I also authorize any former employer, person, firm, corporation, or government agency to give Crossroads Repair, LLC any information they may have pertaining to me. In consideration of Crossroads Repair, LLC’s review of this application, I release Crossroads Repair, LLC and all providers of information from any liability as a result of furnishing and receiving this information.

1. Do you agree with the above statements? *

   Yes, I do