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Pump Department
Lee360 Program
Case Studies
History
Contact Us
Employment
HDPE Proven
Fusion Department
Fabrication
Pipe Yard
McElroy Fusion Equipment
Highlighted Products
HydroBlox
Elgin Lighting
PE Damage Indicator
Flexamat
SOLMAX Mirafi
Tenax Polypropylene Roof & Rib Controls
Specialty Fabrication
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Employment Application
An Equal Opportunity Employer. We consider applications for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, sexual orientation, citizen status, genetic ininformation or any other legally protected status.
PERSONAL INFORMATION
Name
First
Middle
Last
Social Security No.
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Primary Phone
Secondary Phone
Email
How were you referred?
GENERAL INFORMATION
Are you under the age of 18?
Yes
No
If so, Can you supply working papers?
Yes
No
U.S. Citizens or aliens who have the legal right to work in the U.S. are eligible for employment. Upon employment, can you provide genuine documentation establishing your identity?
Yes
No
A conviction record will not necessarily negate your chances of employment. Factors such as job relations, age, time of offense, seriousness, nature of violation, and rehabilitation will all be considered.
Have you ever been convicted of a felony?
Yes
No
If Yes, please explain.
Have you ever been discharged from employment or forced to resign?
Yes
No
If Yes, please explain.
IF YOU HAVE ANY QUESTIONS CONCERNING THE POSITION, PLEASE ASK THE INTERVIEWER BEFORE ANSWERING.
JOB INTEREST
Type of work desired
Position(s) desired
Wage Desired
Date Available to Start
MM slash DD slash YYYY
Work Availability
Please check all that apply.
Full
Part
Overtime, if required
Weekends, if required
Seasonal
Temporary
Conditions of employment are listed at the end of this form. Please read carefully before you sign this application. Application must be completed in full even if attaching a resume. Job applications are considered active for 60 days, after which, the applicant must reapply for further consideration.
EMPLOYMENT HISTORY
Begin with your most recent employment, continuing with your past employment for the last 5 years. All Driver Applicants must provide information on all previous employers for the last three years. List the complete mailing address including street number, city, and zip code. Applicants driving a commercial motor vehicle in interstate or intrastate must provide an additional 7 years of information.
Employer Name
Job Title
Dates Employed
Employer Address
Description of Duy
Starting Wage
Ending Wage
Employer Phone No.
Reason for leaving
May we contact?
Yes
No
Explanation of any period between jobs:
Were you subject to the FMCSR during this employment?
Yes
No
Was your job designated a safety sensitive function?
Yes
No
Were you subjected to DOT regulated drug and alcohol testing requirements of 49 CFR Part 40?
Yes
No
Employer Name
Job Title
Dates Employed
Employer Address
Description of Duy
Starting Wage
Ending Wage
Employer Phone No.
Reason for leaving
May we contact?
Yes
No
Explanation of any period between jobs:
Were you subject to the FMCSR during this employment?
Yes
No
Was your job designated a safety sensitive function?
Yes
No
Were you subjected to DOT regulated drug and alcohol testing requirements of 49 CFR Part 40?
Yes
No
Employer Name
Job Title
Dates Employed
Employer Address
Description of Duy
Starting Wage
Ending Wage
Employer Phone No.
Reason for leaving
May we contact?
Yes
No
Explanation of any period between jobs:
Were you subject to the FMCSR during this employment?
Yes
No
Was your job designated a safety sensitive function?
Yes
No
Were you subjected to DOT regulated drug and alcohol testing requirements of 49 CFR Part 40?
Yes
No
DRIVING INFORMATION
Any applicant applying for a position requiring driving must complete the following section. Accident record for the previous 5 years.
License Type
Issuing State
License No.
Expiration Date
Driving Incidents:
Date of Accident
Type of Accident
Fatalities or Injuries
Yes
No
Hazardous Material Spill
Yes
No
Date of Accident
Type of Accident
Fatalities or Injuries
Yes
No
Hazardous Material Spill
Yes
No
Date of Accident
Type of Accident
Fatalities or Injuries
Yes
No
Hazardous Material Spill
Yes
No
If any, Please explain:
Traffic Convictions for the last 3 years:
Date
Location
Charge
Penalty
Date
Location
Charge
Penalty
Date
Location
Charge
Penalty
If any, Please explain:
Driving Experience:
Straight Truck:
FROM
TO
Approximate Miles Driven
Tractor & Semitrailer:
FROM
TO
Approximate Miles Driven
Tractor & Two Trailers:
FROM
TO
Approximate Miles Driven
Tractor & Triple Trailers:
FROM
TO
Approximate Miles Driven
Other:
FROM
TO
Approximate Miles Driven
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
Yes
No
Has your license, permit, or privilege ever been cancelled, denied, suspended, or revoked?
Yes
No
Have you ever tested positive for alcohol or a controlled substance?
Yes
No
Have you ever been convicted or pled guilty or no contest to a DWI/DUI or any drug or alcohol related offense?
Yes
No
Are you currently taking any medications prescribed or otherwise that could affect your ability to drive a vehicle safely?
Yes
No
If you answered yes to any of the above questions, please provide details:
List any driving classes or awards you have received:
EDUCATION
High School, Graduated:
Yes
No
Name & Address:
Degree:
College, Graduated:
Yes
No
Name & Address:
Degree:
Graduate School, Graduated:
Yes
No
Name & Address:
Degree:
Trade School, Graduated:
Yes
No
Name & Address:
Degree:
Other, Graduated:
Yes
No
Name & Address:
Degree:
REFERENCES
Name
Phone No.
Relationship
Years Known
Name
Phone No.
Relationship
Years Known
Name
Phone No.
Relationship
Years Known
Name
Phone No.
Relationship
Years Known
ADDITONAL QUALIFICATIONS OR EXPERIENCE
List any other Skills, Qualifications, or Experience you believe will help you in being considered for the position you applied for.
Skills
Qualification
Experience
ADDITIONAL COMMENTS OR CONCERNS
Conditions of employment are listed at the end of this form. Please read carefully before you sign this application. Application must be completed in full even if attaching a resume. Job applications are considered active for 60 days, after which, the applicant must reapply for further consideration.
NOTIFICATION AND AGREEMENT
I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE, AND COMPLETE. I UNDERSTAND THAT THE FALSIFICATION, MISREPRESETNATION, OR OMISSION OF FACT ON THIS APPLICATION (OR ANY OTHER ACCOMPANYING OR REQUIRED DOCUMENTS) WILL BE CAUSE FOR DENIAL OF EMPLOYMENT OR IMMEDIATE TERMINATION OF EMPLOYMENT, REGARDLESS OF WHEN OR HOW DISCOVERED. Questions regarding this statement should be directed to any employment interviewer before signing. The application will be given every consideration, but its receipt does not imply that the applicant will be employed. It is the policy of Lee Supply Company, Inc. to afford equal opportunity to all employees and applicants for employment without regard to age, race, religion, color, sex, national origin, marital status or pregnancy, and to afford equal opportunities to disabled veterans, veterans of the Vietnam era, and individuals with a disability, any and other characteristic protected by Federal, State, or Local law. I authorize the investigation of all statements and information contained in this application. I release from all liability anyone supplying such information and I also release the employer from all liability that might result from making an investigation. I hereby certify that all the facts and information listed on this employment application are true and complete. I understand that any false, incomplete, or misleading information given by me on this application is sufficient cause for rejection of this application. I also understand and agree that any such false, incomplete, or misleading information discovered on this application at any time after I am employed my result in dismissal. If I am offered employment, I understand that such an offer will be conditioned upon satisfactory results of a background investigation and/or company medical examination or inquiry, including a drug-screening test. I consent to the investigation, physical and drug test. I hereby authorize Lee Supply Company, Inc. to investigate all statements contained in this application, to interview the references and previous employers listed in the application (unless otherwise noted), and to obtain a report from a consumer- reporting agency to be used for employment purposes in accordance with the Fair Credit Reporting Act. I authorize the references and previous employers listed to give Lee Supply Company, Inc. all facts, opinions, and evaluations concerning my previous employment and any other information they may have, personal or otherwise, and release all such information to Lee Supply Company, Inc., including, but not limited to, any liability or invasion of privacy. I understand that I will be provided with a separated consent form authorizing a consumer report and/or investigative consumer report. If I am applying for a position as a driver with Lee Supply Company, Inc., I understand that information I provide regarding current and/or previous employers may be used, and those employers contacted for investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to: a) Review information provided by previous employers; b) Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer, and; c) Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information. In consideration of my employment, I agree to conform to the company’s rules and regulations, and I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company’s option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice at any time by the company. I further understand and voluntarily agree as a condition of employment or my continued employment, that I may be requested by Lee Supply Company, Inc. to submit to a urinalysis or other drug screen test and that my failure to take such test(s) when requested to do so or unsatisfactory test results will disqualify me from consideration for employment, or if I am then employed, may result in immediate dismissal. I acknowledge that I have a valid driver’s license in one of the 50 United States. I acknowledge that I have read and understand the above statements and herby grant permission to confirm the information supplied on this application by me.
Name
First
Last
Date
MM slash DD slash YYYY
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