Pel State – Non-DOT Application

Pel-State

NON-DOT APPLICATION FOR EMPLOYMENT

PEL STATE SERVICES

We are an Equal Opportunity Employer. No question on this application is intended to be discriminatory
under any applicable Federal, State or Local Fair Employment Practices Law.

NON-DOT EMPLOYMENT APPLICATION

II. EMPLOYMENT INTERESTS

If yes name them

III. EDUCATION INFORMATION

IV. SKILLS - If applicable for which you are applying

WPM

Employment Information.

Start with current or most recent employer.

Employer #1

Employer #2

Employer #3

Employer #4

EMPLOYER AUTHORIZATION

I authorize any person, school, current employer (except as expressly noted), past employer(s), and organizations named in this application form (and accompanying resume or other documentation, if any) to provide relevant information and opinion, personal or otherwise, that may be useful in making a hiring decision. I release all parties from all liability for any damage that may result from furnishing information and opinion to you.

In consideration of employment, I agree to obey the rules and standards of this company. I understand that nothing contained in this application or in the interview process is intended to create a contract between this company and myself for either employment or for the providing of any benefits. I agree that my employment is at-will and the. Terms of employment may be changed with or without cause, with or without notice, including but not limited to termination, demotion, promotion, transfer, compensation, benefits duties and location of work, at any time, for any reason, at the option of myself or this company. This constitutes my entire agreement with this company with regard to the length of my employment.

I understand that as a condition of employment I may be required to take a post-offer/pre-employment physical examination that may include an alcohol and drug test. I further understand that at any time during my employment, I may be required to take a physical examination which may include an alcohol and drug test If management reasonably suspects a condition exists that will prevent me from performing my job in a manner that does not endanger my own health or the safety and health of others. I authorize all providers of health care who examine me to disclose to this company or its agents, all medical information revealed during such examinations. I further authorize this company to disclose such information to any other persons, if at any time my medical condition is put at issue in any proceeding by myself or others. In the event that I have a disability that will affect my ability to test, I will so Inform this company so that a reasonable accommodation can be made. This company reserves the right to require medical documentation concerning the need for accommodation.

I understand that all offers of employment are conditioned upon my providing satisfactory documentary proof of my identity and legal right to live and work In the United States.

I hereby acknowledge that I have read the above statements and understand them. I certify that I, the undersigned applicant, have personally completed this application. I declare under penalty of perjury that the facts contained in the application (or any resume or other documents submitted) are true and complete to the best of my knowledge. I understand that any misrepresentations or omissions will disqualify me from further consideration for employment, and will be justification for my dismissal from employment, if discovered a later date.

CONSENT TO OBTAIN AND RELEASE DRIVING RECORD INFORMATION

CONSENT TO BACKGROUND INVESTIGATION

This document is:

  1. My consent for any state to release driving record information.
  2. My consent for my employer or prospective employer, their insurance agents, assigns or insurance company to secure my driving record and detailed information.
  3. The original of this document may be held by my employer, their insurance agents, assigns or insurance company and copies of this document and my motor vehicle record may be provided as necessary.
  4. Consent to background investigation.

By signing this form, i give my consent and release as noted above. This shall remain in full force and effect until i file a formal written withdrawl with my employer, their insurance agents and their insurance company.

Background Release & Authorization Form

PLEASE PROVIDE US WITH YOUR HOME ADDRESS FOR THE PAST *SEVEN* YEARS.

Current Address

From - To

Previous Address #1

From - To

Previous Address #2

From - To

Previous Address #3

From - To

URINALYSIS AND BREATH ANALYSIS CONSENT FORM

I understand that Pel State requires pre-employment drug and alcohol testing of all applicants. I further understand that Pel State's conducts random drug testing as required by law.

I consent to the urine sample collection and testing for controlled substances and the breath sample collection and testing for alcohol, both pre and post-employment.

I understand that a verified positive test result for controlled substances and/or alcohol concentration will render me unqualified for employment with Pel State. Results will be reported to Pel State by the independent testing facility contracted to conduct these tests. If the results are positive, the controlled substance will be identified.

These results will not be released to any other parties without my written consent.