Employment Application

Voluntary Survey

Check One:	Female     Male
Race:	Asian/Pacific Islander     Black     Hispanic
	American Indian/Alaskan Native     White

Physical Nature of Work: An Industrial Painter is required, to stand and squat for long periods; regularly lift, carry & control objects in excess of 80 lbs, occasionally lift, carry and control objects in excess of 110 lbs, precisely control tools with over 120 PSI of backpressure, climb vertically & diagonally, work odd hours & long shifts. Are you able and willing to perform all of these tasks?    Yes     No

If no, please state specifically which functions of the position you are unable to perform. If you are able to partially perform the function, state the extent of your limitation:

Veteran: Have you served in the United States Armed Forces?    Yes     No

If yes, please advise which branch and years served:  

Veterans Preference: Are you entitled to any preference or special consideration under any statute dealing with Veterans?    Yes     No

APPLICATION FOR EMPLOYMENT

*Are you a member of a Union?    Yes     No
If yes, what trade?       Union State?   
                   Local #      District Council #   

*Have you worked for us before?    Yes     No
If yes, when?   

Have you applied for work with us before?    Yes     No
If yes, when?   

Why did you apply with this company?

Employee Referral?

Name if relatives employed by this company:

*Are you willing to work out of State?

Educational Background

High School:       Last year attended:     1     2     3     4
Graduated?         Major:   

College:               Last year attended:     1     2     3     4
Graduated?         Major:   

Other Training (Include Apprenticeship):

Are you willing to do:   High Work?    Swingstage?    Confined Space?

Do you have a current First Aid Card?    Yes     No    CPR Card?    Yes     No

Do you have reliable transportation?    Yes     No

Have you worked for a Department of Transportation (DOT) regulated company within the past two (2) years?    Yes     No

Professional Background

Journeyman?    Apprentice?    Bracket#   

Describe non-paint related skills:

Do you smoke?       Do you chew?   

Are there any other issues or factors we need to know about to assist us in placement?   
If yes, please describe:   

While Hartman Walsh Painting Company provides protective equipment for you, the work of industrial painting can expose to you thinners, solvents, epoxies, and other toxic vapors and dusts. Are you able to perform the job in the presence of these hazardous chemicals while using personal protective equipment?

Regular attendance is an essential function of any position with the Company. When assigned to a project you may be required to work away from home, up to 12 hours per day, 7 days per week. Are you able to satisfy these attendance requirements?
Yes     No
If you are restricted in some manner in the location or scheduling of your work, please state in detail the specific restrictions as to location and/or schedule:

Previous Employers

Personal References

Many of our customers, including Government agencies, require full disclosure of criminal convictions and may restrict access to their site based on this information. A conviction will not necessarily bar you from employment. Failure to disclose convictions, however, is cause for immediate termination.

Have you ever been convicted of a felony?     Yes     No     If yes, describe in full:

Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by a company to which you applied for in the past two (2) years?     Yes     No

If yes, describe in full:

MEDICAL REVIEW

All medical information disclosed in this application will be treated as sensitive and confidential personal information.

Emergency Instructions

Are there any other emergency instructions, medical needs, allergic responses, or procedures the company should know?

Health and Safety

*Have you ever had any injuries on the job?     Yes     No

*Do you have or have you had other injuries or illnesses not on the job (home, auto, sports, hunting, etc.) that have resulted in hospitalization, surgery, or lost work time?     Yes     No

*Are you taking any long term (more than 30 days) prescribed medication?     Yes     No

*Do you have or have you been diagnosed as having any illness or injury for which you are not seeking treatment?     Yes     No

If yes, please describe:

Comments

Please use this area to provide any additional information:

AFFIRMATION AND AUTHORIZATION

I hereby affirm that the Medical Review information on this form is true and correct, and that there are no omissions, false information, or misrepresentation of facts. I authorize any physician, medical facility, law enforcement agency, administrator, state agency, institution, information service bureau, insurance company, or employer contacted by this company or an agent of this company to furnish or verify workers compensation information and medical records.

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY:

Applicant agrees to the following conditions of employment:

1. A pre-placement health evaluation, if required, including laboratory testing for drug or alcohol use prior to employment.
2. Submitting proof of citizenship or immigration status upon employment.
3. Completing and executing surety bond application, if required.
4. Meeting attendance and performance requirements.
5. Conforming to the policies and procedures of the company rules, regulations and instructions.
6. Testing for illicit substances as per the policy statement published by the Company.
7. Applicant understands that employment is based on specific project needs and may be terminated or require layoff as the project work force needs dictate.
8. Applicant understands that any employee who personally or as a result of instructions to his/her subordinate(s) pollutes or causes the possibility of injury or damage to the environment, persons or property, in complete disregard of common sense and/or applicable company, local, state and/or federal laws or regulations shall be subject to immediate dismissal.

I certify that all the facts and statements in this application are true and complete to the best of my knowledge. I understand that any falsified statements on this application or omission of fact either on this application or during the pre-employment process will result in my application being rejected, or, if I am hired, in my employment being terminated.

I understand that in accepting this application, the company is in no way obligated to provide me with employment and that I am not obligated to accept employment if offered. I understand that acceptance of an offer of employment does not create a contractual obligation upon the employer to continue to employ me in the future. I hereby understand and acknowledge that, unless otherwise defined by applicable law, and subject to the terms of any applicable collective bargaining agreement, any employment relationship with Hartman Walsh Painting Company is an "at will" nature, which means that I may resign at any time and Hartman Walsh Painting Company may discharge me at any time with or without cause.It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by the board of directors.

I understand that the Company's office is located in Missouri and I understand that I may be assigned to work in various States for various periods of time, but that all essential details regarding my employment are developed and administered in Missouri and that wherever I am assigned to work, my ultimate reporting location is in Missouri. Therefore, I acknowledge that if employed by the Company, I will be considered to be employed in the State of Missouri irrespective of the location of the particular job on which I am working.

I have been advised that Hartman Walsh Painting Company may request an investigative consumer report to be prepared on all information contained herein. I hereby give consent for a consumer report for employment purposes. I hereby authorize, without reservation, any law enforcement agency, administrator, state agency, state repository, former employer, corporation, credit agency, educational institution, city, state, federal court, military institution, information service bureau, or employer contacted by Hartman Walsh Painting Company to furnish any and all information. I do understand the investigation will include information from former employers, law enforcement agencies, state agencies and public records information, such as credit, criminal, and motor vehicle. This report will include information as to my character, work habits, performance and experience, along with the reasons for termination or past employment from previous employers. My signature below releases any aforesaid parties from any liability and responsibility for collecting the above information at any time.

If an investigative consumer report is obtained you must provide, at my request, the name of the agency so I may obtain from them the nature and substance of the information contained in the report.

Please enter your name and today's date to indicate your consent to the agreement above.
*   *
You may be required to sign a physical copy of your application at a future date.
Your IP Address will be recorded with the submission of your application.