APPLICATION FOR EMPLOYMENT
Please fill out the application in full. Applicants with disabilities may request accommodations needed to participate in the application process. We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, sex, age, national origin, marital status, or disability.

Date: September 20, 2017

Personal Information
Name(Last)
Name(First)
Middle Initial
Home Phone
(-
Address (Street)
City
State
Zip Code
Cell/Alternate Phone
(-
Are you at least 18 years of age?
Yes No
Do you have a valid Driver's License?
Yes No
(Class/Endorsements)
Are you legally entitled to work
in the United States?
Yes No
Email Address


Position
Position Desired
Will Accept:
Full-Time

Part-Time

Temporary

(Check at least one box)
Date Available to Start
Have you applied or worked here before?
Yes No

If so, when and what position?
Are you currently employed?
Yes No

If so, may we contact your current employer?
Yes No

Hours Available to Work
Desired Wage/Salary
Salary at current or previous job
Are you able to perform the essential functions of the job you are applying for, with or without reasonable accommodation? Yes No


Education
Do you have a High School diploma or G.E.D.?  Yes No If no, what is the highest grade you completed?
College / Technical School Education
Name of School Location No. of Yrs. Graduate? Type of Degree, Diploma, or Certificate
Yes No
Yes No
Yes No
Are you a Veteran of Military Service?  Yes No


Skills
List any special skills or equipment that you can operate that is pertinent to the position you are applying for:


Employment History
List your employment history starting with the most recent.
Employer
Length of Employment:

FROM (Month/Year):
/
TO (Month/Year):
/

Total: Years, Months
Address
Phone Number
(-
Supervisor
Your Job Title
Supervisor's Title
Principal Responsibilities
Reason for Leaving

#2 (Next most recent).
Employer
Length of Employment:

FROM (Month/Year):
/
TO (Month/Year):
/

Total: Years, Months
Address
Phone Number
(-
Supervisor
Your Job Title
Supervisor's Title
Principal Responsibilities
Reason for Leaving

#3 (Next most recent).
Employer
Length of Employment:

FROM (Month/Year):
/
TO (Month/Year):
/

Total: Years, Months
Address
Phone Number
(-
Supervisor
Your Job Title
Supervisor's Title
Principal Responsibilities
Reason for Leaving


References
List two references who have knowledge of your work performance within the last three years.
Name
Occupation
Phone
(-
Number of Years Acquainted

Name
Occupation
Phone
(-
Number of Years Acquainted


Resume
(OPTIONAL) Attach a Resume:
Filetypes accepted: 
• Microsoft Word (.doc)
• Microsoft Excel (.xls)
• Adobe Reader (.pdf)
• Text (.txt)

By checking the box below and typing my complete name in leiu of my signature, I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery. I hereby authorize E.H. Lawrence Company, Inc. to thoroughly investigate my references, work record, criminal history, education, and other matters related to my suitability for employment. I understand that nothing contained in the application or conveyed during any interview which may be granted is intended to create an employment contract between me and E.H. Lawrence Company, Inc.

I agree Signed:


---

Equal Opportunity Employment Information
The information requested below will be used to meet reporting requirements pertaining to equal employment opportunity. Furnishing the information is voluntary. It will not be kept in personnel files and will not be used in the hiring process. We encourage your assistance in our efforts to provide equal opportunity in employment.
Gender
Male
Female
Race/Ethnic Group
CAUCASIAN (Not of Hispanic origin), including persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.
BLACK OR AFRICAN AMERICAN – All persons having origins in any of the Black African racial groups; not ofHispanic origin.
HISPANIC OR LATINO – Persons of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of race.
AMERICAN INDIAN OR ALASKAN NATIVE – All persons having origins in any of the original peoples of North America.
ASIAN OR PACIFIC ISLANDER – All persons having origins in any of the original peoples of the Far East, SE Asia, the Indian subcontinent or the Pacific Islands.
Disability Status
A person with a disability is defined as:
1 - Having a physical or mental impairment which substantially limits one or more major life activities.*
2 - Having a record of such an impairment.
3 - Being regarded as having such an impairment.
*Major life activities include caring for oneself, performing manual tasks, walking, talking, hearing, seeing, speaking, breathing, learning, and working.
Note: Temporary, non-chronic impairment of short duration, with little or no long-term impact, are usually not disabilities. A visual problem which has been corrected by glasses is usually not a disability. Veterans who are treated as “disabled” by the Veterans Administration are not automatically “disabled” under this definition.

Based on the above information, do you claim disability status?
Yes No


Enter the characters from the image above: