PERSONAL INFORMATION
Address:*
Address:
City:*
State:
Zip Code:*
E-mail:
Phone:
Home:
Cell:
Location and Position applying for:
Sumner
Maltby
Seattle Tacoma
Foreman Lead
Operator
Driver
Laborer
Traffic
Control Supervisor
Flagger
Mechanic
Mechanic Helper
* Are you at least 18 years of age? YES
NO
Will
Visa or immigration status prevent lawful employment?
YES
NO
Have you ever worked for AA Asphalting, Inc. before? YES
NO
If YES, please describe, including dates of
employment, rate of pay, position, and your reason for
leaving.
Were you referred by someone? YES
NO
If yes, who?
EMPLOYMENT
HISTORY
All Applicants must
provide the following information for current or
previous employers during the preceding 3 years.
Applicants to drive a
commercial motor vehicle in intrastate or interstate
commerce (lead, foreman, and driver positions)
must provide an additional 7 years of employment
information for those employers of whom the applicant
operated such vehicle.
Are you currently
employed? YES
NO
If NO, what was your last date of employment?
mon
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2011
2012
year
NOTE: List employers in reverse order starting with
your current or most recent.
We will not contact your current employer without your
permission.
Is this your
current employer? YES
NO
If YES, may we contact this employer? YES
NO
Dates:
From:
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2006
2007
2008
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2010
2011
2012
year
Employer:
Address:
City:
St.
Zip:
Contact:
Telephone:
Duties:
Position Held:
Wage:
Reason for leaving:
CLICK
HERE IF DONE ENTERING EMPLOYERS
Dates:
From:
mon
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
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2006
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2008
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2010
2011
2012
year
Employer:
Address:
City:
St.
Zip:
Contact:
Telephone:
Duties:
Position Held:
Wage:
Reason for leaving:
CLICK
HERE IF DONE ENTERING EMPLOYERS
Dates:
From:
mon
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
day
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1999
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2004
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2010
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2012
year
To:
mon
JAN
FEB
MAR
APR
MAY
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JUL
AUG
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OCT
NOV
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day
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1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
year
Employer:
Address:
City:
St.
Zip:
Contact:
Telephone:
Duties:
Position Held:
Wage:
Reason for leaving:
CLICK
HERE IF DONE ENTERING EMPLOYERS
Dates:
From:
mon
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
day
1
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1999
2000
2001
2002
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2010
2011
2012
year
To:
mon
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
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OCT
NOV
DEC
day
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year
Employer:
Address:
City:
St.
Zip:
Contact:
Telephone:
Duties:
Position Held:
Wage:
Reason for leaving:
If you still need
more room, please use the following fill-in form and be
sure to include the same information as above:
SKILLS
TRAINING & QUALIFICATION
Indicate your level of
education:
Grade
School 1 2
3 4
5 6
7 8
High School: 9
10 11
12
Technical or Trade School: 1
2
3
4
College: 1 2
3 4
Last School Attended:
List any special
training programs you have participated in:
Summarize your
special skills or qualifications as they pertain to the
job you are applying for:
What types
(include makes/models) of construction equipment can you
operate or repair?
If the position you are applying for involves the
driving/operation of vehicles or equipment, do you have
a valid license?
YES
NO
If Yes, provide
license
#
State:
Expires on:
SKILLS
TRAINING & QUALIFICATION
Applicants
to drive a commercial motor vehicle in intrastate or
interstate commerce (lead, foreman, and driver
positions) must complete this section.
Explain
any gaps in employment during the past three years
Dates
From:
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30
31
1995
1996
1997
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1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
year
To
mon
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
day
1
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1995
1996
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2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
year
Explain:
Dates From:
mon
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
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day
1
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2010
2011
2012
year
To
mon
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
day
1
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1995
1996
1997
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2006
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2007
2008
2009
2010
2011
2012
year
Explain:
Dates From:
mon
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
day
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1995
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2008
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To
mon
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
day
1
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1996
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2006
2007
2008
2009
2010
2011
2012
year
Explain:
Dates From:
mon
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
day
1
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1995
1996
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2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
year
To
mon
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
day
1
2
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2011
2012
year
Explain:
Provide living addresses for the past three years:
Street
City
State &
ZIP
How Long?
Street
City
State &
ZIP
How Long?
Have you had a
motor vehicle accident within the past 3 years?
YES
NO
If
yes, please explain each incident. Include the
date, the nature (head-on, rear-end, etc), indicate if
there were any injuries or fatalities:
Have you had a
traffic conviction (other than parking violations)
within the past 3 years?
YES
NO
If
yes, please explain each incident. Include the
date, the location, charge of conviction, and penalty:
Have you ever been
denied a license, permit, or privilege to operate a
motor vehicle?
YES
NO
Have you ever had your license, permit, or privilege
suspended or revoked?
YES
NO
If the answer to either question above is YES, please
provide details:
Please indicate
your driving experience
Equipment Class
Equipment Type
Dates
Mileage
Straight
Truck
Van Tank Flat
Other
From
mon
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
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OCT
NOV
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25
26
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29
30
31
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
year
To
mon
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
day
1
2
3
4
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1970
1971
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1984
1985
1986
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1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
year
in thousands
Tractor&Semi-Trailer
Van Tank Flat
Other
From
mon
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
day
1
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27
29
30
31
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
year
To:
mon
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
day
1
2
3
4
5
6
7
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9
10
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1970
1971
1972
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1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
year
in thousands
Tractor-2
Trailers
Van Tank Flat
Other
From
mon
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
day
1
2
3
4
5
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8
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10
11
12
13
14
15
16
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18
19
20
21
22
23
24
25
26
27
29
30
31
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
year
To:
mon
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
29
30
31
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
year
in thousands
Other
(list)
Van Tank Flat
Other
From
mon
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
day
1
2
3
4
5
6
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8
9
10
11
12
13
14
15
16
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18
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21
22
23
24
25
26
27
29
30
31
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
year
To:
mon
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
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24
25
26
27
29
30
31
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
year
in thousands
Other
(list)
Van Tank Flat
Other
From
mon
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
day
1
2
3
4
5
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7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
29
30
31
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
year
To:
mon
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
29
30
31
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
year
in thousands
List states
operated in for last 5 years:
List special
driving courses or training you have received:
List any safe
driving awards you hold and who issued them:
Are you at least
21 years of age?
YES
NO
Date Of Birth
mon
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
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DEC
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1950
1951
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1957
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1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
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1972
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1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
2010
2011
2012
year
AVAILABILITY AND
READINESS TO WORK
On what date would
you be available to start?
mon
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
day
1
2
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2011
2012
2013
Are you available
to work:
Full Time
Part Time
Temporary
2nd Shift
Are you on lay-off
or subject to recall?
YES NO
Can you travel if
a job requires it?
YES NO
TO BE READ AND SIGNED
BY APPLICANT
All
applicants must complete
the following section. Please check the "I
Agree" box if you agree to be bound by the
pertaining statement.
Have you ever been convicted of a
felony or released from prison within the past ten years
for an offense which may reasonably relate to the job
duties of the position for which you are applying? (Due
to federal regulations, a conviction may disqualify you
from employment as a driver) Conviction of a crime is
not an automatic bar to employment.
YES
NO *
If yes, please explain:
"I authorize investigation of
all information provided during the application process
and the references listed above to give the Company any
and all information concerning my previous employment
and any pertinent information they may have, personal or
otherwise and release from liability or responsibility
this Company, its agents and all persons, companies or
corporations providing information to the Company about
me."
I Agree *
"I understand the company
reserves the right to condition my employment upon a
satisfactory pre-employment drug test."
I Agree *
"I understand that if I am
employed, the company reserves the right to subject me
to drug and alcohol testing if applicable government
regulations so require, or if there is reasonable
suspicion that I am using drugs or that I am under the
influence of drugs or alcohol."
I Agree *
"I understand and agree that, if
I am employed, I will be an "at will" employee
and agree that the employment relationship can be
terminated at any time with or without cause by me or by
the company. I understand that no representative
of the Company other than in writing, signed by the
President of the Company and by me, has any authority to
enter into an agreement of employment for any specified
period of time , or which is otherwise inconsistent with
the "at will" employment relationship."
I agree *
"If employment is obtained under
this application, I will comply with all of the rules
and policies of my employer."
I agree *
"I certify that the facts
contained in this application are true and complete to
the best of my knowledge. I understand that, if
employed, false information, misrepresentation of facts,
and material omissions shall be grounds for denial of
employment, or discharge if hired. I agree to hold my
employer harmless in the event of denial or discharge on
these grounds."
I Agree *
All applicants
must electronically "sign" this application by
entering their FULL name in the signature box and
selecting the date of submission. Incomplete,
improper, or unsigned applications may be rejected out
of hand and without cause.
* Signature
* Date:
mon
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2012
Your
application will be submitted immediately upon clicking
the "Submit" button. Before doing so, it
is strongly suggested that you scroll back up and check
your application for completeness and correctness.
Clicking
on Submit will process your application through our
secure site and direct you to a confirmation page.