Apply for Experienced Paving Crew Member

>> Experienced Paving Crew Member >> Apply

Please fill out the form below and click Submit to submit your application for consideration. Fields with an asterisk (*) are required.

Summary
Title:	Experienced Paving Crew Member
ID:	3397
Location :	Grove City (PA)
Contact Information
* First Name:
* Last Name:
* Middle Initial:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Primary Phone:
* Email:
Application Information
* Source:
* If Referral, provide Name:	If referred by an employee, please provide employee name.
* If other, please specify:
If Newspaper, provide name:
If Radio, provide name:
If TV, provide channel:	Provide the name of the television channel where you saw the advertisement (i.e. ESPN)
* Former Employee:	Have you ever worked for this company before?
Employee Number:	Please provide employee number if current employee.
* Army PaYS Program:	Are you a participant in the Army PaYS Program?

GOH, Inc Employment Application

PERSONAL INFORMATION

* Are you legally authorized to be employed in the United States? (Proof of identity and work authorization documentation will be required as a condition of employment.):

Yes No

* Will you at any time require sponsorship for work authorization?:

Yes No

* Are you at least 18 years or older? (If no, you may be required to provide authorization to work):

Yes No

* Have you ever worked for this Company before?:

Yes No

If Yes, please provide details (Where/When/Job Title):

EMPLOYMENT DESIRED

* When would you be available to begin work?:

* Type of employment desired:

Full-Time
Part Time
Seasonal
Internship

* Hourly rate/salary desired:

* Are you currently employed?:

Yes No

If so may we inquire of your present employer?:

Yes No

If presently employed, why are you considering leaving?:

EDUCATION

Give record of all High Schools, Colleges, Universities and Vocational/Technical Schools you have attended.

School Name & Location	Did you Graduate?	Degree Received	Subjects Studied/Major
	Yes No
	Yes No
	Yes No

If you have completed any special courses, seminars and/or training that would help you to perform the position for which you are applying, please describe:

REFERENCES Please provide three references (not relatives).

Name	Relationship	Phone Number
*	*	*
*	*	*
*	*	*

AUTHORIZATION

-I swear/affirm that the statements and information I have provided in this Application for Employment are true, correct, and complete to the best of my knowledge.
-I certify that I have answered all questions to the best of my ability and have not withheld any information that would unfavorably affect my application for employment. I acknowledge that misrepresentation or omissions may be the cause for my rejection for employment or may result in my subsequent dismissal if I am hired. I specifically, acknowledge that the employer will use my driver record abstract(s) required pursuant to Section 6-114 of the Pa Vehicle Code for the purposes identified and for no other purpose.
-I hereby consent to have GOH, Inc. contact anyone it deems appropriate to investigate or verify any information I have provided or to discuss my background, past performance, or suitability for employment. I expressly consent to any discussions regarding the foregoing by any person contacted. I knowingly and voluntarily waive all rights to bring any actions for defamation, invasion of privacy, or similar cause of action against anyone providing such information. This affidavit is filed in compliance with Section 607 of the Fair Credit Reporting Act.
-I understand that employment at GOH, Inc. is "at-will" which means that either I or GOH, Inc. can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statute. All employment is continued on that basis. I understand that no leader, supervisor, manager, or executive of GOH, Inc., other than the President, has the authority to create an employment contract other than an at will employment contract and the President may only do so in writing that is signed by both the President and the employee in question. I represent and warrant that I am not subject to any covenant or other restriction, including non-compete and/or non-solicitation agreements, that would preclude me from accepting employment at GOH and performing all duties associated with the position for which I am applying.

* Signature (type name):

* Date:

Driver's Questions

This questionnaire is part of the Application for Employment. This information will be used when related to essential functions of the position.

TO BE READ AND SIGNED BY APPLICANT

I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a condtional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in consideration with my application.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand also, that I am required to abide by all rules and regulations of the company.

I understand that information I provide regarding current and / or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (o). I understand that I have the right to:

Review information provided by current/previous employers
Have errors in the information corrected by previous employers and for those employers to re-send the corrected information to the prospective employer; and
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.

* Signature (type name):

* Date:

PERSONAL INFORMATION

List previous addresses of residency for the past 3 years (if different from current).

Street	City	State	Zip Code	Number of Years

EMPLOYMENT INFORMATION

All applicants wishing to drive in interstate commerce must provide the following information on all employers during the preceeding three years. You must give the same information for all employers for whom you have drive a commercial vehicle seven years prior to the initial three years (total of ten employment records).

You are required to list the complete mailing address; street number and name city, state and zip code.

EMPLOYER 1

Dates Employed	Employer Name & Address	Employer Phone
From: * To: *	* *	*
Job Title	Supervisor Name & Title	May we Contact?
*	* *	* Yes No
Responsibilities	Reason for Leaving	Salary/Hourly Rate
*	*	Start: * End: *
WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS?		* Yes No
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR, PART 40?		* Yes No
ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason:

EMPLOYER 2

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Job Title	Supervisor Name & Title	May we Contact?
		Yes No
Responsibilities	Reason for Leaving	Salary/Hourly Rate
		Start: End:
WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS?		Yes No
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR, PART 40?		Yes No
ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason:

EMPLOYER 3

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Job Title	Supervisor Name & Title	May we Contact?
		Yes No
Responsibilities	Reason for Leaving	Salary/Hourly Rate
		Start: End:
WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS?		Yes No
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR, PART 40?		Yes No
ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason:

EMPLOYER 4

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Job Title	Supervisor Name & Title	May we Contact?
		Yes No
Responsibilities	Reason for Leaving	Salary/Hourly Rate
		Start: End:
WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS?		Yes No
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR, PART 40?		Yes No
ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason:

EMPLOYER 5

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Job Title	Supervisor Name & Title	May we Contact?
		Yes No
Responsibilities	Reason for Leaving	Salary/Hourly Rate
		Start: End:
WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS?		Yes No
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR, PART 40?		Yes No
ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason:

EMPLOYER 6

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Job Title	Supervisor Name & Title	May we Contact?
		Yes No
Responsibilities	Reason for Leaving	Salary/Hourly Rate
		Start: End:
WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS?		Yes No
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR, PART 40?		Yes No
ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason:

EMPLOYER 7

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Job Title	Supervisor Name & Title	May we Contact?
		Yes No
Responsibilities	Reason for Leaving	Salary/Hourly Rate
		Start: End:
WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS?		Yes No
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR, PART 40?		Yes No
ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason:

EMPLOYER 8

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Job Title	Supervisor Name & Title	May we Contact?
		Yes No
Responsibilities	Reason for Leaving	Salary/Hourly Rate
		Start: End:
WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS?		Yes No
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR, PART 40?		Yes No
ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason:

EMPLOYER 9

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Job Title	Supervisor Name & Title	May we Contact?
		Yes No
Responsibilities	Reason for Leaving	Salary/Hourly Rate
		Start: End:
WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS?		Yes No
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR, PART 40?		Yes No
ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason:

EMPLOYER 10

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Job Title	Supervisor Name & Title	May we Contact?
		Yes No
Responsibilities	Reason for Leaving	Salary/Hourly Rate
		Start: End:
WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS?		Yes No
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR, PART 40?		Yes No
ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason:

EMPLOYER 11

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Job Title	Supervisor Name & Title	May we Contact?
		Yes No
Responsibilities	Reason for Leaving	Salary/Hourly Rate
		Start: End:
WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS?		Yes No
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR, PART 40?		Yes No
ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason:

EMPLOYER 12

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Job Title	Supervisor Name & Title	May we Contact?
		Yes No
Responsibilities	Reason for Leaving	Salary/Hourly Rate
		Start: End:
WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS?		Yes No
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR, PART 40?		Yes No
ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason:

EMPLOYER 13

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Job Title	Supervisor Name & Title	May we Contact?
		Yes No
Responsibilities	Reason for Leaving	Salary/Hourly Rate
		Start: End:
WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS?		Yes No
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR, PART 40?		Yes No
ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason:

EMPLOYER 14

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Job Title	Supervisor Name & Title	May we Contact?
		Yes No
Responsibilities	Reason for Leaving	Salary/Hourly Rate
		Start: End:
WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS?		Yes No
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR, PART 40?		Yes No
ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason:

EMPLOYER 15

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Job Title	Supervisor Name & Title	May we Contact?
		Yes No
Responsibilities	Reason for Leaving	Salary/Hourly Rate
		Start: End:
WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS?		Yes No
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR, PART 40?		Yes No
ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason:

EMPLOYER 16

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Job Title	Supervisor Name & Title	May we Contact?
		Yes No
Responsibilities	Reason for Leaving	Salary/Hourly Rate
		Start: End:
WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS?		Yes No
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR, PART 40?		Yes No
ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason:

EMPLOYER 17

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Job Title	Supervisor Name & Title	May we Contact?
		Yes No
Responsibilities	Reason for Leaving	Salary/Hourly Rate
		Start: End:
WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS?		Yes No
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR, PART 40?		Yes No
ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason:

EMPLOYER 18

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Job Title	Supervisor Name & Title	May we Contact?
		Yes No
Responsibilities	Reason for Leaving	Salary/Hourly Rate
		Start: End:
WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS?		Yes No
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR, PART 40?		Yes No
ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason:

EMPLOYER 19

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Job Title	Supervisor Name & Title	May we Contact?
		Yes No
Responsibilities	Reason for Leaving	Salary/Hourly Rate
		Start: End:
WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS?		Yes No
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR, PART 40?		Yes No
ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason:

EMPLOYER 20

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Job Title	Supervisor Name & Title	May we Contact?
		Yes No
Responsibilities	Reason for Leaving	Salary/Hourly Rate
		Start: End:
WERE YOU SUBJECT TO THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS?		Yes No
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR, PART 40?		Yes No

*Any gaps in employment and/or unemployment must be explained

**The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more. (Refer to Section 390.5 of Federal Motor Carrier Safety Regulations for definition.)

EXPERIENCE AND QUALIFICATION

Driving Experience

If no driving experience within the last 3 years

Check here

Class of Equipment		Check Type of Equipment	Date From(M/Y)	Date To(M/Y)	Approx No. of Miles (Total)
* Straight Truck	Yes No
* Tractor and Semi-Trailer	Yes No
* Tractor - Two Trailers	Yes No
* Tractor - Three Trailers	Yes No
* Motorcoach - School Bus (Greater than 8 passengers)	Yes No
* Motorcoach - School Bus (Greater than 15 passengers)	Yes No
* Tri Axle Dump	Yes No
* Lowbed / Flatbed	Yes No
Other:

Accident History

If no accidents within the last 5 years

Check here

Date	Nature of Accident (Head-on, Rear-End, Upset, Etc.)	Injuries	Fatalities	Haz Mat Spill

Traffic Convictions and Forfeitures (5 years)

If no Traffic Convictions and/or Forfeitures within the last 5 years

Check here

Date (Month/year)	Violation (Other than violations involving parking only)	State of Violation	Penalty (Forfeited bond, collateral and/or points)

State	License No.	Expiration Date	Class	Endorsements
*	*	*	*	H N T P S X

Section 383.21 FMOSR states "No person who operates a commercial motor vehicle shall at any time have more than one driver's license". I certify that I do not have more than one motor vehicle license, the information for which is listed below.

* Have you ever been denied a license, permit or privilege to operate a motor vehicle?

Yes No

If yes, give details.

* Has any license, permit or privilege ever been suspended or revoked?

Yes No

If yes, give details.

APPLICANT CERTIFICATION This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

* Applicant's Signature (type name):

* Date:

Personal Identifying Questions

This questionnaire is part of the Application for Employment. This information will be used when related to essential functions of the position.

* Social Secuity Number::

* Date of Birth::

Paving & Milling Questions

This questionnaire is part of the Application for Employment.

* How many years of paving experience do you have?

* How many years of milling experience do you have?

What equipment have you operator?

What equipment listed above are you most comfortable operating?

* Do you have a Class B Driver's License?

	Yes
	No

* Do you have a Class A Driver's License?

	Yes
	No

* Do you have any experience working on PennDOT jobs?

	Yes
	No

* Do you have any experience working on parking lots?

	Yes
	No

* Do you have any experience working on townships jobs?

	Yes
	No

veteran pre-offer

Invitation to Self-Identify

VETERANS

Glenn O. Hawbaker, Inc. is a Government contractor subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications are defined as follows:

A "disabled veteran" is one of the following:
- A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or
- A person who was discharged or released from active duty because of a service-connected disability.
A "recently separated veteran" means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.
An "active duty wartime or campaign badge veteran" means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.
An "Armed forces service medal veteran" means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

Protected veterans may have additional rights under USERRA—the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor's Veterans Employment and Training Service (VETS), toll-free, at 1-866-4-USA-DOL.

If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below. As a Government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.

I identify as one or more of the classifications of Protected Veteran listed above.
I am not a Protected Veteran

Voluntary Self-Identification of Disability CC-305

Voluntary Self-Identification of Disability

Form CC-305
OMB Control Number 1250-0005
Expires 01/31/2017

Why are you being asked to complete this form?

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities.ⁱ To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

How do I know if I have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

Disabilities include, but are not limited to:

Blindness
Deafness
Cancer
Diabetes
Epilepsy

Autism
Cerebal palsy
HIV/AIDS
Schizophrenia
Muscular dystrophy

Bipolar disorder
Major depression
Multiple sclerosis (MS)
Missing limbs or partially missing limbs

Post-traumatic stress disorder (PTSD)
Obsessive compulsive disorder
Impairments requiring the use of a wheelchair
Intellectual disability (previously called mental retardation)

Please check one of the boxes below:

YES, I HAVE A DISABILITY (or previously had a disability)
NO, I DON'T HAVE A DISABILITY
I DON'T WISH TO ANSWER

* Signature (type name):

* Date:

Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

ⁱSection 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor's Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.

Fair Credit Reporting Act Notification

FAIR CREDIT REPORTING ACT DISCLOSURE

Glenn O. Hawbaker, Inc. (the "company") intends to obtain and use a consumer report and/or an investigative consumer report from an external consumer reporting agency for employment purposes. These reports may be obtained at any time after the company receives authorization from you, including any time during the period of your employment if the company hires you. These purposes may include but are not limited to:

considering your application for employment;
making a decision whether to offer you employment with the company;
deciding whether to continue your employment (if you are hired by the company);
doing periodic rescreening of current employees, and/or;
making any other employment decisions affecting you, including promotion, retention, and/or reassignment.;

A consumer reporting agency is a person or business that regularly assembles or evaluates consumer credit information or other information on consumers. As an applicant or an employee, you are considered a "consumer" under the Fair Credit Reporting Act.

A consumer report may include, but is not limited to, information about your character; general reputation; personal characteristics that may be used for employment purposes; mode of living, including credit history and reports; verification of social security number; previous and current residences; employment history; motor vehicle records; criminal history, including reports from any criminal justice agency in any or all federal, state, or county jurisdictions; and, any other public records. An investigative consumer report includes similar information as consumer reports, which are obtained through personal interviews with those who are acquainted with you or who may have knowledge of any relevant information about you.

You have a right to request disclosures of the nature and scope of any investigative consumer report that the company obtains about you. A summary of your rights under the Fair Credit Reporting Act (“FCRA”) is being provided to you along with this Disclosure. This information is also available at: www.consumer.ftc.gov/articles/pdf-0096-fair-credit-reporting-act.pdf

AUTHORIZATION

I acknowledge that I have received and read the Fair Credit Reporting Act Disclosure, a Summary of Consumer Rights under the Fair Credit Reporting Act, and this authorization. I hereby authorize Glenn O. Hawbaker, Inc. and any authorized agents or third party agents pursuant to the Fair Credit Reporting Act to obtain consumer reports and/or investigative consumer reports about me from a consumer reporting agency and that they may consider information in consumer reports and investigative consumer reports as part of their decision making process regarding any aspect of my application for employment and/or employment related matters, including periodic rescreening of current employees. I agree and understand that these reports may be obtained at any time after giving this authorization, including at any time during my employment if I am hired, without additional authorization, including authorization to run periodic checks of my Motor Vehicle Record. I authorize any individual or entity having personal knowledge of me to furnish Glenn O. Hawbaker, Inc, or its designated agents with any and all information regarding me in connection with this authorization and which will be used for employment related matters by Glenn O. Hawbaker, Inc. I further authorize and acknowledge that a copy of this authorization shall be accepted with the same authority as an original. I also acknowledge that I have received a copy of the Summary of Rights under the Fair Credit Reporting Act. I certify that the information provided on this form is true and correct. I understand that any information that I provide in an employment application or that I otherwise disclose during my employment may be used to obtain consumer reports and/ or investigative consumer reports.

* Signature (type name):

* Date:

Submit

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	1 or more
	2 or more
	3 or more
	4 or more
	5 or more

	Less than 1
	1 or more
	2 or more
	3 or more
	4 or more
	5 or more

	Screed
	Paver
	Paving Roller
	Shuttle Buggy
	Widener
	Dirt Roller
	Grader
	Miller
	Distributor Truck
	Service Truck
	Water Truck
	Nuclear Density Gauge
	Skid Loader
	Backhoe/Loader

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