Job Application - Apply To Bothar Construction

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Date*

Are you 18 years or older?*

Yes
No

Are you prevented from lawfully becoming employed in this country because of Visa or immigration status?*

Yes
No

Employment Desired

Salary Desired

Date you can start

Are you employed now?

Yes
No

If so may we inquire of your present employer

Yes
No

Are you willing to travel?

Yes
No

Outside of NY

Yes
No

Are you currently on lay-off status and subject to recall?

Yes
No

Ever applied to this company before?

Yes
No

When?

Referred By

Education

Select all that applies

Grammar School
High School
College
Trade, Business or Correspondence School

Grammar School

Name of School

Address

Street Address City State / Province / Region ZIP / Postal Code

Number of years attended

Subjects studied

Did you graduate?

Yes
No

High School

Name of School

Address

Street Address City State / Province / Region ZIP / Postal Code

Number of years attended

Subjects studied

Did you graduate?

Yes
No

College

Name of School

Address

Street Address City State / Province / Region ZIP / Postal Code

Number of years attended

Subjects studied

Did you graduate?

Yes
No

Trade, Business or Correspondence School

Name of School

Address

Street Address City State / Province / Region ZIP / Postal Code

Number of years attended

Subjects studied

Did you graduate?

Yes
No

Special Skills/Certifications

Have you ever taken an OSHA 10 or 30 Hour Safety Course

Yes
No

If yes can you provide documentation

Yes
No

Former Employers

(list below last 4 employers, starting with the most recent)

Start/End date	Name & Address	Phone Number	Postilion	Reason for Leaving

References

(Give the names of three persons not related to you, whom you have known at least one year)

Three References

Name	Address	Phone Number	Business	Years Acquainted

Driving & Accident Information

(I understand that if this position requires a valid driver's license, proof will be required after hire)

Drivers Licenses Class (A,B,D)

State of License

Endorsements

Do you have a valid medical examiners certificate (DOT Medical Card)?

Yes
No

Date of Exam

Expiration Date on Card

BOTHAR Construction, LLC*

BOTHAR Construction, LLC performs highway and road construction which requires strenuous activities including heavy lifting, long hours and difficult weather conditions. If you are not in good physical shape or have difficulties performing physical labor you may not wish to work at BOTHAR Construction, LLC. By completing this application you are acknowledging these conditions and are aware of the risks associated with this type of work if not performed properly. “ I certify that the information in this application is true and understand that misrepresentations or false or omitted facts may result in my termination, regardless of the time of discovery by the company. I also understand that, if hired, my employment is for no definite period and may be terminated at any time without written notice and that, absent a written contract signed by the Members of the company, I will remain an at-will employee and can be terminated at any time without any notice. I authorize investigation of the statements contained herein and the references listed above to give you any and all information concerning my previous employment and any pertinent information such references may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you.”

First Last

Date*

BOTHAR Construction, LLC

ADDITIONAL APPLICANT DATA Applicants are considered for all positions, and employees are treated during employment without regard to age, race, creed, color, national origin, sexual orientation, military status, sex, disability, predisposing genetic characteristics, marital status, pregnancy, domestic violence victim status, or any other basis prohibited by local, state or federal law to refuse to hire or employ or to bar or to discharge from employment such individual or to discriminate against such individual in compensation or in terms, conditions or privileges of employment. Government agencies at times require periodic reports on the sex, ethnicity, disability, veteran and other protected status of applicants. This data is for analysis and possible affirmative action only. Solely to help us comply with government record keeping, reporting and other legal requirements, we request that you also fill out the tear-off sheet. This data is for periodic government reporting and will be kept in a confidential file separate from your Application for Employment.

Name

First Last

Position Applied For

Phone

Date

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Invitation to Self-Identify

Bothar Construction LLC. complies with federal and state regulations pertaining to affirmative action, equal opportunity, and nondiscrimination. We ask your assistance in helping us meet our federal and state compliance obligations of monitoring recruitment, promotion and retention. This data is for periodic government reporting. This information is voluntarily provided; it will be kept confidential; and refusal to provide it will not subject any employee to any adverse treatment. If you choose not to self-identify your gender/race/ethnicity currently, the federal government requires this employer to determine this information by visual survey and or other available information.

Referral Source

Check one

Male
Female

Check one

White
Asian
Black or African American
Hispanic or Latino
American Indian or Alaskan Native
Native Hawaiian or Pacific Islander

Veteran Status

VETERAN OF THE VIETNAM ERA -A veteran, any part of whose active military, naval or air service was during the period August 5,1964 through May 7, 1975, who: Served on active duty for a period of more than 180 days and was discharged or released there from with other than a dishonorable discharge or (2) was discharged or released from active duty because of a service-connected disability.
SPECIAL DISABLED VETERAN - (i)A veteran 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 Veteran Administration for a disability: (A) rated at 30% or more, or (B) rated at 10 0r 20% in the case of a veteran who has been determined under Sect. 3106 of Title 38 USC to have a serious employment handicap; (ii) a person who was discharged or released from active duty because of service-connected disability.
OTHER PROTECTED VETERANS - A veteran who served on active duty in the ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized.
INDIVIDUAL WITH A DISABILITY - Any person who (1) has a physical or mental impairment which substantially limits one or more of such person’s major life activities, (2) has a record of such impairment, or (3) is regarded as having such an impairment. For purposes of this part, a handicapped individual is “substantially limited” if he or she is likely to experience difficulty in securing, retaining or advancing in employment because of a handicap.
RECENTLY SEPARATED VETERANS - A veteran during the three-year period beginning on the date of such veterans’ discharge Or release from active duty in the U.S. Military, ground, naval or air service.
N/A - Not Applicable

Apply

Step 1 of 2

Employment Desired

Education

Grammar School

High School

College

Trade, Business or Correspondence School

Former Employers

Driving & Accident Information

References

CERTIFICATION AND RELEASE

BOTHAR Construction, LLC

Invitation to Self-Identify

Employment Desired

Education

Grammar School

High School

College

Trade, Business or Correspondence School

Former Employers

References

Driving & Accident Information

BOTHAR Construction, LLC

Invitation to Self-Identify

Step 1 of 2

Employment Desired

Education

Grammar School

High School

College

Trade, Business or Correspondence School

Former Employers

Driving & Accident Information

References

CERTIFICATION AND RELEASE

BOTHAR Construction, LLC

Invitation to Self-Identify