News | Atsalis Brothers Painting

Personal Information

Name*

First Middle Last

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

Mobile Phone

Email Address*

Enter Email Confirm Email

Preferred method of contact?

Preferred method of contact?*

Phone

Email

Are you 18 years or older?

Are you 18 years or older?*

Yes

No

Social Security Number

Social Security Number*

Are you authorized to work in the United States?

Are you authorized to work in the United States?*

Yes

No

Have you been previously employed here?

Have you been previously employed here?*

Yes

No

Have you filed an application with us before?

Have you filed an application with us before?*

Yes

No

How did you hear about us?

What method of transportation will you use to come to work?*

Atsalis employees are required to travel. I understand this policy and can travel.

Atsalis employees are required to travel. I understand this policy and can travel.*

Yes

No

Have you ever been convicted of a crime?

Have you ever been convicted of a crime?*

Yes

No

Do you have a valid driver's license?

Do you have a valid driver's license?*

Yes

No

What languages can you fluently understand and read?*

List professional trade, business or civic activities and offices held excluding groups the name or character of which indicate race, color, religion, sex, national origin, handicap, marital or veterans status, height, weight, or age

State any additional information that you feel may be helpful to us in considering your application.

Employment Desired

Position(s) applied for

Position(s) applied for*

Kind of work sought

Kind of work sought

Full time

Part time

Other

Salary Desired

Salary Desired

Date available to work

Date available to work*

Employment Experience (1 of 4)

List current or most recent job first. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.

Employer One

Employer Name*

Work Performed*

Work Address*

Street Address City State ZIP Code

Phone*

Dates Employed

Hourly Rate / Salary

From Date*

To Date*

Starting*

Ending*

Job Title*

Supervisor*

Reason for Leaving*

Employment Experience (2 of 4)

List current or most recent job first. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.

Employer Two

Employer Name

Work Performed

Work Address

Street Address City State ZIP Code

Phone

Dates Employed

Hourly Rate / Salary

From Date

To Date

Starting

Ending

Job Title

Supervisor

Reason for Leaving

Employment Experience (3 of 4)

List current or most recent job first. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.

Employer Three

Employer Name

Work Performed

Work Address

Street Address City State ZIP Code

Phone

Dates Employed

Hourly Rate / Salary

From Date

To Date

Starting

Ending

Job Title

Supervisor

Reason for Leaving

Employment Experience (4 of 4)

List current or most recent job first. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.

Employer Four

Employer Name

Work Performed

Work Address

Street Address City State ZIP Code

Phone

Dates Employed

Hourly Rate / Salary

From Date

To Date

Starting

Ending

Job Title

Supervisor

Reason for Leaving

Skills

SPECIALIZED SKILLS

Check the Skills/Equipment Operated

Sand Blasting

Pressure Cleaning

Spray Painting

Scaffolding

Supervision

Other

Do you have any reason you cannot work in confined areas above ground?*

Yes

No

OTHER EQUIPMENT WITH WHICH YOU ARE EXPERIENCED:

References

Reference One

Name*

First Last

Reference 1*

Street Address Address Line 2 City State ZIP Code

Phone*

Years Acquainted*

Reference Two

Name*

First Last

Reference 2*

Street Address Address Line 2 City State ZIP Code

Phone*

Years Acquainted*

Reference Three

Name*

First Last

Reference 3*

Street Address Address Line 2 City State ZIP Code

Phone*

Years Acquainted*

Education

High School

Years Completed

Diploma / Degree

Location

Courses of Study

College

Years Completed

Diploma / Degree

Location

Courses of Study

Graduate

Years Completed

Diploma / Degree

Location

Courses of Study

Vocational / Training

Years Completed

Diploma / Degree

Location

Courses of Study

Any other educational training:

Emergency Contacts

IN CASE OF EMERGENCY

(Person(s) to be notified in the event of an accident or emergency)

Primary Emergency Contact Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Work Phone

Mobile Phone

Secondary Emergency Contact Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Work Phone

Mobile Phone

Authorization

Employers must make accommodations to disabled applicants and employees where the accommodation does not impose an undue hardship on the employer. Under Michigan law, only, disabled employees and applicants may request an accommodation of their disability by notifying the company in writing of the need for accommodation within 182 days of the date and disabled individual knows or should know that an accommodation is needed. This requirement does not apply to an individual's right under the Americans with Disabilities Act. Failure to properly notify the company may preclude any claim that the employer failed to accommodate the disabled individual.

AUTHORIZATION AND UNDERSTANDING:

Upon the signing of this application, I represent that all of the information now or hereafter given by me in support of my application is true and complete. I authorize you to verify any of the information concerning my employment, education, criminal history, or medical records, with the appropriate individuals, companies, institutions or agencies, and I authorize then to release such information as you require, including my prior disciplinary employment record, without any obligation to give me written notice of such disclosure. I also authorize you to release any information requested by any of my prospective or subsequent employers without any obligation to give me written notice of such disclosure. I hereby release you and them from any liability whatsoever as a result of any such inquiries and disclosures, and this release from liability does not waive nor prohibit an individual from filing a charge of discrimination under the laws enforced by the EEOC. I agree that any false information in support of my application may subject me to discharge at any time during the period of my employment.

I agree that either party may terminate the employment relationship, with or without cause, at any time, and I further agree that this arrangement may only be altered in writing directed to me personally and signed by the president of the company. I agree that I shall be bound by the other rules, policies, regulations and terms and conditions of employment of the company as they are from time to time changed, and no additional obligations can be imposed on the Company except those which have been acknowledged in writing, by the president or his designated representatives. I hereby authorize the company to deduct from each and every pay period of my pay any amounts necessary to offset any damages caused by me or the value of property or money entrusted to me by, or owed by me to the company during the course of my employment.

I agree that any action or suit against the company, its agents or employees, arising out of my employment or termination of employment, including, but not limited to, claims arising under State, but not Federal, civil rights statutes, must be brought within 180 days of the event giving rise to the claims or be forever barred. I waive any limitation periods to the contrary. I further agree that if I should bring any non-statutory action or claim arising out of my employment against the company, in which the company prevails, I will pay the company any and all such costs incurred by the company in defense of said claims or actions, including attorney fees. I further agree that my employment is conditional until such time as the results of my post-offer physical (if such physical is required) are known.

Agree to Conditions Checkbox 1*

I agree to the terms and conditions above

Please print your name*

Date*

DISCLOSURE AND AUTHORIZATION FOR RELEASE OF INFORMATION

As part of our hiring background and investigation, we may obtain consumer reports to prepare an investigative consumer report. The investigative consumer report may consist of contacting all listed prior employers to verify your employment history. It may also include, but not limited to, credit information reports, criminal history reports and driving history reports. Under the provision of the Fair Credit Reporting Act (15 USC at 1681-1681u) as amended, before we can see such reports, we must have your written permission to obtain the information. You have the right, upon written request to complete an accurate disclosure of the nature and scope of the investigation. you are also entitled to a copy of your Consumer Rights under the Fair Credit Reporting Act.

AUTHORIZATION AND RELEASE TO OBTAIN INFORMATION

Under the provisions of the Fair Credit Reporting Act, 15 USC, Section 1681 et seq., the Americans with Disabilities Act and all applicable federal, state, and local laws, I hereby authorize and permit Atsalis Brothers Painting Company/Atsalis Brothers Construction and it's Agents to obtain a consumer report and/or investigative consumer report which may include the following:

My employment records.
Records concerning any driving, criminal history, credit history, civil record, workers' compensation and drug testing.
(For truck drivers only) In accordance with the Department of Transportation Motor Carrier Safety Regulations, Section 382.413, information concerning alcohol and controlled substances for the past 2 years.
Verification of my academic and/or professional credentials, and information and/or copies of documents from any military service records.

I authorize Atsalis Brothers to receive and review my medical records from occupational Clinic.

I understand that an "investigative consumer report" may include information as to my character, general reputation, personal characteristics, and mode of living, which may be obtained by interviews with individuals with whom I am acquainted or who may have knowledge concerning any such items of information.

I agree that a copy of this authorization has the same effect as an original.

I hereby release and hold harmless any person, firm or entity that discloses matters in accordance with this authorization, as well as Atsalis Brothers Painting/Atsalis Brothers Construction Company and it's Agents from liability that might otherwise result from the request for use of and/or disclosure of any or all of the foregoing information.

I understand and acknowledge that under provisions of the Fair Credit Reporting Act, I may request a copy of any consumer report from the consumer-reporting agency that compiled the report, after I have provided proper identification.

I hereby authorize Atsalis Brothers Painting/Atsalis Brothers Construction Company and it's Agents to obtain and prepare an investigative consumer report as set forth above, as part of its investigation of my employment application.

Agree to Conditions Checkbox 2*

I agree to the terms and conditions above

Please print your name*

Date*

DISCLAIMER: THIS FORM IS NOT MEANT TO PROVIDE LEGAL ADVICE OF ANY KIND. LEGAL ADVICE SHOULD BE GIVEN ONLY BY YOUR ATTORNEY. WE MAKE NO CLAIMS, PROMISES, OR GUARANTEES ABOUT THE ACCURACY, COMPLETEDNESS OR ADEQUACY OF THE INFORMATION CONTAINED HEREIN AND NO CLAIM THAT THIS FORM IN APPROPRIATE FOR YOUR PARTICULAR NEEDS.

Please ensure that you have provided all necessary information prior to submission. I understand that by hitting the submit button I am providing an electronic signature on this application and my typed name above shall have the same force and effect as my written signature.

Phone

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