Employment Application

Application For Employment

List last four employers, starting with the most recent

Name
and Address

Reason
for Leaving

Position Applied for	Type of employment	Social Security Number
	Full Time Part Time

Last Name	Middle Name	First Name

Previous name(s)

Permanent address	How long at current address?	E-Mail

Address 2	City	State	Zip

Home Phone	Cell Phone	FAX Number

Are you employed now?	May we contact your present employer?	Are you on layoff and subject to recall?
Yes No	Yes No	Yes No

Are any of your relatives employed here?	If Yes, provide name	and relationship
Yes No

Are you prevented from lawfully becoming employed in the US
because of visa or immigration status?

Yes No

Are you a veteran of US Military Service?	Branch?
Yes No	Army Navy Air Force Marines Coast Guard Reserves

Can you pass a Motor Vehicle screen?	Can you pass a drug screen? *	Have you ever been arrested? *	Have you ever been convicted of a felony? *
Yes No	Yes No	Yes No	Yes No

* Be accurate! Your answers will be matched against actual results of drug screens and criminal background checks.

Date you can start work	Minimum salary requirements

Are you able to perform the essential functions of the position for which you are applying?

Yes No

Are accommodations necessary for you to perform these duties?

Yes No

If yes, please describe:

Which state(s) would you prefer to work in? (check all which apply)

AL AK AS AZ AR CA CO CT DE DC
FL GA GU HI ID IL IN IA KS KY
LA ME MD MA MI MN MS MO MT NE
NV NH NJ NM NY NC ND OH OK OR
PW PA PR RI SC SD TN TX UT VT
VI VA WA WV WI WY

Is relocation applicable?	If so, how soon could you relocate?
Yes No

For Installation or Construction positions: Do you have (check all which apply)

Truck Ladders/Meters Tools General Liability Insurance

Experience:

(check the areas in which you are experienced)
Installation	Construction	Administrative
Installation CLI Pre-Positive MDU Drops Telephony/VoIP HSD/DVR/VOD	Underground Aerial Activation/Splicing Fiber	Clerical (office) Accounting Payroll Management Human resources

Have you ever worked with us before?	Where?
Yes No

Name of the last company you worked for

Did you attend/graduate Amtec College?	If yes, graduation date:
Yes No

What is your management experience?

Education

	Name and location of school	Years attended	Graduated?	Subjects Studied
High School
Trade, Bus. or Correspondence
College/ University
Graduate Studies

Former Employers

References

Provide the names of three persons NOT related to you, who have known you at least one year
Name	Address	Telephone	Years known	Occupation

Additional Information

Provide any additional information you feel may be helpful to us in considering your application

In Case of Emergency, please notify

Name	Telephone	Relation

Authorization:

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.
I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release Amtec, LLC (hereinafter referred to as“Amtec”) from all liability for any damage that may result from utilization of such information. I hereby authorize Amtec to conduct or cause to be conducted, thorough investigation concerning my background, and myself including a criminal investigation and a consumer investigation report, a drug screening test, and a Motor Vehicle Report, or anyone or combination of these reports in connection with my application for employment. I agree to cooperate in any such investigation and understand that any offer of employment
by Amtec or continued employment (if already employed) is contingent upon the satisfactory results of such investigation.
I acknowledge and agree that Amtec may obtain information pursuant to such investigation through personal interviews with acquaintances,business associates, and other persons that may have knowledge as to my personal and professional background. I further acknowledge and agree that inquiry into my character,personal characteristics, credit, employment history, military history, and public record information (i.e. record of civil judgments, indictments, convictions, motor vehicle violations, tax liens, or bankruptcy information) as well as diplomas, degrees, licenses and transcripts may be relevant to Amtec’s evaluation of my qualifications and that such inquiry will be made pursuant to such investigation.
I also understand and agree that no representative of Amtec has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized Amtec representative.
This application is current and active for only 30 days. At the conclusion of this time, if I have not had any contact from Amtec and still wish to be considered for employment, it will be necessary for me to fill out a new application.
In authorizing such investigation, I hereby provide the following supplemental data to ensure that any records located which may referto a person with a name identifiable or similar to mine are properly determined as referring to or not to me.

Resume Upload:

File:

Date

February 22, 2012