GRAYCO CABLE SERVICES, INC
Application for Employment

APPLICANTS MAY BE TESTED FOR ILLEGAL DRUGS
Personal Information
Last  First  Middle  Maiden  

Present Address:
Number  Street  City  State  Zip

How long at this address? yrs mo

Social Security No:

Telephone:    Date of Birth: (for purposes of potential background check)

Position Applied For:   Salary Desired:

If applying for a technician, are you able to work 12 hours per, six days per week? Yes    No

How many hours can you work weekly?    Can you work nights?  Yes    No

Employment Desired:
Full-Time Only   Part-Time Only   Full or Part Time

When are you available for work?

Education
TYPE OF SCHOOL
NAME OF SCHOOL
LOCATION (Street Address)
NUMBER OF YEARS COMPLETED
MAJOR & DEGREE
High School
College
Business or Trade School
Professional School

Background Information

HAVE YOU EVER BEEN CONVICTED OF A MISDEMEANOR OR FELONY?   Yes    No

If yes, explain the number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.


WHERE DID YOU HEAR ABOUT GRAYCO CABLE SERVICES, INC? 

MAY WE CONTACT YOUR PRESENT EMPLOYER? Yes    No


Driving Information
DO YOU HAVE A DRIVER’S LICENSE? Yes    No
What is your means of transportation to work?

Driver’s License Number: State of Issue:

License Type:
Operator Commercial (CDL) Chauffer

Driver’s License Expiration Date:

Have you had any accidents during the past three years? Yes    No         How many?

Have you had any moving violations during the past three years? Yes    No        How many?


References
Please list two references other than relatives or previous employers:
  Reference #1   Reference #2
Name Name
Position Position
Company Company
Address Address
Telephone Telephone

Physical Limitations
If applying for a technician position, do you have any physical limitations or medical condition that would prevent you from:
Lifting objects over 20 pounds?
Climbing Ladders
Working in Extreme Heat
Yes
Yes
Yes 		No
No
No

If yes, please explain:
Military
HAVE YOU EVER BEEN IN THE ARMED FORCES?
ARE YOU NOW A MEMBER OF THE NATIONAL GUARD?
 Yes
Yes		 No
No

Specialty  Date Entered Discharge Date


Work Experience
1) Name of Employer
City State Zip Code
Phone Number   
Name of Supervisor
Employment Dates (From) (To)
Pay or Salary (Start) (Final)
Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company
2) Name of Employer
City State Zip Code
Phone Number   
Name of Supervisor
Employment Dates (From) (To)
Pay or Salary (Start) (Final)
Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company
3) Name of Employer
City State Zip Code
Phone Number   
Name of Supervisor
Employment Dates (From) (To)
Pay or Salary (Start) (Final)
Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company


PLEASE READ CAREFULLY

APPLICATION WAIVER In exchange for the consideration of my job application by Grayco Cable Services, Inc. (hereinafter called the "Company"), I agree that:

Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of Grayco Cable Services, Inc., or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by an Authorized Manager of the Company. Both the undersigned and Grayco Cable Services, Inc. may end the employment relationship at any time, without specified notice or reason.If employed, I understand that the Company may unilaterally chance or revise their benefits, policies and procedures and such changes may include reduction in benefits.

I authorize investigation of all statements contained in this application.I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice.I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contract.

I also understand that (1) the Company has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy.I further understand that continued employment may be based on the successful passing of job-related physical examinations.

I understand that, in connection with the routine processing of your employment application, the Company may request from a consumer reporting agency an investigative consumer reporting including information as to my credit records, character, general reputation, personal characteristics, and mode of living.Upon written request from me, the Company, will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act.

I further understand that my employment with the Company shall be probationary for a period of sixty (60) days, and further that at any time during the probationary period or thereafter, my employment relation with the Company is terminable at will for any reason by either party.

Signature of Applicant (I have read and agree to the above statements)


This company is an equal employment opportunity employer.We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications.

THANK YOU FOR COMPLETING THIS APPLICATION AND FOR YOUR INTEREST IN OUR BUSINESS