WE’RE HIRING! CLICK TO JOIN OUR TEAM. Application For Employment Horsfield Companies, Inc. is an Equal Opportunity and Affirmative Action Employer. Women and minorities are encouraged to apply. NOTICE TO THE APPLICANT: This application is used to evaluate your qualifications for employment. Please answer ALL questions completely. This application is not an employment contract. PLEASE COMPLETE THE FORM BELOW OR CLICK HERE TO DOWNLOAD AND MAIL IN APPLICATION Mail application to: 505 East Main Street, Epworth, IA 52046 Position Applying For * Ex: Concrete Laborer, Pipe Laborer, Truck Driver, etc. Date * MM DD YYYY Personal Information Name * First Name Last Name Social Security Number * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Number * (###) ### #### Date of Birth * MM DD YYYY Sex Male Female Ethnic Origin White Hispanic American Indian/ Alaskan Native Black Asian/ Pacific Islander Other Check any of the following that are applicable Vietnam Era Veteran Disabled Veteran Disabled Individual Email Address * Are you fluent in any languages other than English? * Yes No If yes, list other languages. Referred by? Are you eligible for employment in the United States? * Yes No Experience What date can you start? * MM DD YYYY Are you available to work * Full Time Part Time Summer Temporary Have you worked for this company before? * Yes No Can you travel if a job requires it? * Yes No Are you currently on lay off and subject to recall at another company? * Yes No Do you have a valid driver's license? * Yes No If so, what type? License Number Expiration Date MM DD YYYY State of Issue List any acquired job related skills you'd like us to know about, as well as any training programs you have completed or any equipment you are able to operate. * Previous Employment List your three most recent positions held, starting with the most recent first. Employer 1 Company Name Dates of Employment Address Address 1 Address 2 City State/Province Zip/Postal Code Country Position Supervisor First Name Last Name Phone Number (###) ### #### Starting Wage Ending Wage Reason for leaving May we contact? Yes No Employer 2 Company Name Dates of Employment Address Address 1 Address 2 City State/Province Zip/Postal Code Country Position Supervisor First Name Last Name Phone Number (###) ### #### Starting Wage Ending Wage Reason for leaving May we contact? Yes No Employer 3 Company Name Dates of Employment Address Address 1 Address 2 City State/Province Zip/Postal Code Country Supervisor First Name Last Name Phone Number (###) ### #### Starting Wage Ending Wage Reason for leaving May we contact? Yes No References Reference 1 First Name Last Name Phone Number (###) ### #### Years Known Relationship Reference 2 First Name Last Name Phone Number (###) ### #### Years Known Relationship Reference 3 First Name Last Name Phone Number (###) ### #### Years Known Relationship Special Skills and Qualifications Summarize any special skills or qualifications acquired from previous employment or other experience. Have you attended * High School College Technical School Please list anything else you'd like us to know about you. VOLUNTARY SURVEY Horsfield Companies Inc. is required by state and federal laws to furnish statistical data and to maintain records of certain population characteristics of those applying for jobs with us. The information you supply will be used for statistical purposes only. If you are offered employment with Horsfield Companies, Inc., it will not be used as employment criteria. Horsfield Companies Inc. is an equal employment opportunity employer supporting diversity in the workplace. Thank you for your cooperation in completing this form. CERTIFICATION & RELEASE I certify that the information contained herein is true, complete and accurate. I understand that false statements or omission on this application my result in rejection of my application, or if employed, discharge at any time during my employment. I authorize investigation of all information herein. I further authorize all individuals, companies, schools, corporations, courts, and law enforcement agencies to give you any and all information concerning me that they may have. I release all parties from all liability for any damage that may result from divulging or using this information. I understand and agree that, if hired, my employment is for definite periods of time and either I or the company may terminate the employment relationship at any time, with or without cause, and with or without notice. The employment relationship exists regardless of any other statements of policies to the contrary. I realize that under certain provisions of the law, I may be required to submit to a post offer pre­employment physical and/or drug and alcohol tests as a condition of my employment. I hereby agree to submit to this examination and/or test and permit disclosure of the results to the company. Signature * Date * MM DD YYYY HORSFIELD COMPANIES 505 E MAIN STREET, EPWORTH, IOWA 52045, UNITED STATES 563-876-3335 LOCATIONSIN THE NEWS Website Design: Mabe Design Co.