An Equal Opportunity Employer*

Application For Employment

* Required Fields
Laborer
Finish Grade Operator
General Operator		 Pipe Layer
Foreman
Project Manager/Estimator
 
Position Applied For:
Years of related experience:
If applying for Finish Grade or General Operator, list experience with the following equipment:
Earth Mover / Scraper
Dozer
Grader
Tracked Backhoe
Rubber Tired Backhoe
Rubber Tired Loader
Tracked Loader
Other:
If applying for Pipe Layer, list experience with the following systems:
Sanitary
Water Mains
Storm Sewer
Butt-fusion welded / HDPE
If applying for Foreman, list experience with the following types of crew:
Pipe Laying
Earth Moving
Concrete
Landfill
Demolition
General Information
SSN:  
Date of Application:  
*Name:  Last First M/I
*Home Phone#:  (Area Code) #
Address:  Street
   City State Zip Code
E-Mail Address:  
On what date will you be
available for work?
How were you referred to Kelchner Inc.?  Newspaper: Employee
   Walk-In Other:
Are you over 18 years of age? Yes: No:
Are you a United States Citizen? Yes: No:
Can you travel if a job requires it? Yes: No:
Have you ever been convicted of a felony within the last 7 years? Yes: No:
(If Yes) Explain:  

Education
High School: Yes: No:
College: Yes: No:
Other: hhi
 Are there other experiences, honors, skills or qualifications which you feel would have a direct relationship to the job for which you are applying?  

Employment History
Company Name:    
Address:    
Phone#    
Supervisors Name & Title:    

Date Started: Position(s) Held:
Date Left:

Reasons for Leaving:  
Duties:  
Starting Salary: $
Final Salary: $
May we contact this employer? Yes: No:



Company Name:    
Address:    
Phone#    
Supervisors Name & Title:    

Date Started: Position(s) Held:
Date Left:

Reasons for Leaving:  
Duties:  
Starting Salary: $
Final Salary: $
May we contact this employer?  Yes: No:


Company Name:    
Address:    
Phone#    
Supervisors Name & Title:    

Date Started: Position(s) Held:
Date Left:

Reasons for Leaving:  
Duties:  
Starting Salary: $
Final Salary: $
May we contact this employer? Yes: No:



Company Name:    
Address:    
Phone#    
Supervisors Name & Title:    

Date Started: Position(s) Held:
Date Left:

Reasons for Leaving:  
Duties:  
Starting Salary: $
Final Salary: $
May we contact this employer? Yes: No:

Certification Information

Please check below if you are certified or have taken a class in any of the following.
OSHA 40-11R Health & Safety Training  Yes: No: Date:
OSHA 8-11R Refresher  Yes: No: Date:
29CFR1910.146 Confined Space Training  Yes: No:
Trench Safety Yes: No:
Other:  

* In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex or national origin, age, marital or veteran status, or the presence of a non-job-related medical condition or handicap.


In the event that you are selected for employment by Kelchner, Inc., you will be required to take a physical exam and urine drug and alcohol screening test. The results of this exam and test will be used to determine your employment eligibility.


I certify that all of my answers to questions on this form are true. I fully understand that I may be discharged for giving false information relative to my employment. In accepting employment, I agree by the rules governing the employees of Kelcher Incorporated. I understand that my employment is at the will of Kelchner Inc. and me, and can be ended with or without cause or notice. By submiting this form I authorize Kelchner Inc. to make investigations of my work history, personal references, credit, criminal and motor vehicle records.

*Date: