Signature of Applicant*

    Date*

    Your Name*

    Your Email*

    Your Full Address (including city and state)*

    Phone Number*

    Position(s) applied for*

    Salary Requirements*

    Hours available*

    Date available for work*

    Are you at least 18 yrs old?
    YesNo

    Were you previously employed by us?
    YesNo

    If yes, when?

    Are there any circumstances that could prevent you from being at work on our regular work hours?
    YesNo

    How did you happen to apply at Crooker Construction, LLC?

    Were you referred by a current Crooker Construction or Precast of Maine employee?
    YesNo

    If yes, who?


    Education: List all schools attended.

    Name & Address of School
    High/Prep

    Graduate?
    YesNo

    Name & Address of School
    College

    Graduate?
    YesNo

    Degree

    Curriculum/Major


    Special Skills: Please list special skills/abilities (i.e., equipment or mechanical experience, licenses, software familiarity, etc.)


    Employment History: List employment history beginning with your two most recent positions.

    Employer #1

    Present/Most Recent Employer*

    Phone*

    Address*

    Supervisor*

    Nature of business*

    Starting Date*

    Ending Date*

    Title(s) and Description of Duties*

    Reason(s) for leaving*

    Which duties would you have preferred to have done more of?*

    Which duties would you have preferred to have done less of?*

    Employer #2

    Previous Employer

    Phone

    Address

    Supervisor

    Nature of business

    Starting Date

    Ending Date

    Title(s) and Description of Duties

    Reason(s) for leaving

    Which duties would you have preferred to have done more of?

    Which duties would you have preferred to have done less of?

    Employer #3

    Previous Employer

    Phone

    Address

    Supervisor

    Nature of business

    Starting Date

    Ending Date

    Title(s) and Description of Duties

    Reason(s) for leaving

    Which duties would you have preferred to have done more of?

    Which duties would you have preferred to have done less of?


    Driver's License Information

    Do you have a valid driver's license?
    YesNo

    Driver's License State:

    Driver's License Number:

    Addresses where applicant resided 3 years preceding application date:

    #1: Street, City, State, Zip

    #2: Street, City, State, Zip

    #3: Street, City, State, Zip


    Please complete if you have a commercial Driver's License (CDL)

    Information for Driver's Licenses Held In The Past 3 Years

    #1

    State:

    License Number:

    Class:

    Endorsement(s):

    Expiration Date:

    Have you ever been denied a license, permit or privilege to operate a motor vehicle?
    YesNo

    Has any license, permit or privilege ever been suspended or revoked?
    YesNo

    Have you ever been disqualified for violations of Federal Motor Carrier Safety Regulations?
    YesNo
    If you answered "yes" to any of the above questions, please explain in the Additional Notes section at the bottom of this form.

    Driving Experience

    Straight Truck

    Type of Equipment (Van/Tank/Flat/Dump)

    Dates (from & to)

    Approximate Total Miles

    Tractor and Semi Trailer

    Type of Equipment (Van/Tank/Flat/Dump)

    Dates (from & to)

    Approximate Total Miles

    Other

    Type of Equipment (Van/Tank/Flat/Dump)

    Dates (from & to)

    Approximate Total Miles

    Accident Review for the Past 3 Years

    #1

    Date

    Nature of Accident (Head-On/Rear-End/Overturn, etc)

    Fatalities

    Injuries

    Additional Notes

    #2

    Date

    Nature of Accident (Head-On/Rear-End/Overturn, etc)

    Fatalities

    Injuries

    If there are any additional accidents to report, please include them in the Additional Notes section at the bottom of this form.

    Traffic Convictions and Forfeitures for the past 3 years

    do not include parking violations

    #1

    Location

    Date

    Charge

    Penalty

    #2

    Location

    Date

    Charge

    Penalty

    If there are any additional traffic convictions to report, please include them in the Additional Notes section at the bottom of this form.


    Applicant's Name

    Date

    CROOKER CONSTRUCTION, LLC IS A FEDERAL GOVERNMENT CONTRACTOR/SUBCONTRACTOR AND IS REQUIRED TO REQUEST THE FOLLOWING INFORMATION FOR AFFIRMATIVE ACTION PURPOSES ONLY.

    Sex
    MaleFemale

    Race
    American Indian or Alaskan NativeBlack, Not of Hispanic OriginAsian or Pacific IslanderHispanicWhite, Not of Hispanic Origin

    PROVIDING THIS INFORMATION IS PURELY VOLUNTARY AND WILL, IN NO WAY, AFFECT YOUR POSSIBLE EMPLOYMENT WITH CROOKER CONSTRUCTION, LLC.

    Additional Notes

    Having trouble with the form please call 207-837-6709.