Employment Application – Weather Craft

Personal Information

Name*

First Last

Address*

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

Email*

Phone*

Mobile

Birth Date*

Place of Birth (City, State)*

ON A SCALE OF 1-5 (1=PERFECT) RATE YOUR DRIVING RECORD?

DID YOU SERVE IN THE UNITED STATES MILITARY?

Yes
No

HAVE YOU WORKED AS A CIVILIAN ON A MILITARY BASE?

Yes
No

HAVE YOU EVER BEEN DENIED ACCESS TO A MILITARY BASE?

Yes
No

DO YOU HAVE ANY RESTRICTION THAT PREVENTS YOU FROM TRAVELING OUTSIDE OF THE AREA?

Yes
No

Education

PROVIDE THE NAME OF THE SCHOOL(S) YOU ATTENDED AND THE LEVELS YOU COMPLETED:

HIGH SCHOOL/GED

TRADE SCHOOL

JR COLLEGE

COLLEGE

DO YOU SPEAK AND UNDERSTAND ENGLISH?

Yes
No

DO YOU SPEAK SPANISH?

Yes
No

WHAT LANGUAGES DO YOU READ AND WRITE?

English
Spanish
Other

Untitled

LIST WORK RELATED TRAINING OR CERTIFICATIONS (e.g. OSHA 10 HOUR, FORK LIFT, CPR) :

Work Experience

DO YOU HAVE PREVIOUS ROOFING / SHEET METAL EXPERIENCE?

Yes
No

HAVE YOU PREVIOUSLY WORKED FOR WEATHERCRAFT?

Yes
No

CHECK THE EXPERIENCE LEVEL YOU ACHIEVED IN ROOFING OR SHEET METAL:

LABOR
APPRENTICE
JOURNEYMAN
FOREMAN
SERVICE LEAD
NO EXPERIENCE

CHECK THE ROOF SYSTEM(S) WITH WHICH YOU HAVE EXPERIENCE:

BUILT UP
MODIFIED BITUMEN
EPDM
TPO/PVC
TILE/SLATE
SHINGLES

CHECK THE SHEET METAL YOU HAVE EXPERIENCE INSTALLING:

COPING
CORRUGATED ROOF
STANDING SEAM ROOF
WALL PANELS

DESCRIBE YOUR EXPERIENCE WITH ROOFING OR SHEET METAL:

PREVIOUS PAY RATE

DESIRED PAY RATE

PLEASE LIST PREVIOUS EMPLOYERS STARTING WITH THE MOST RECENT:

Employer 1

Dates of Employment

Contact Name & Title

Phone Number

WHY DID YOU LEAVE YOUR LAST JOB?

QUIT
LAID OFF
FIRED

DID YOU LEAVE ON GOOD TERMS (ARE YOU ELIGIBLE FOR RE-HIRE)?

Yes
No

Employer 2

Dates of Employment

Contact Name & Title

Phone Number

Employer 3

Dates of Employment

Contact Name & Title

Phone Number

LIST AND DESCRIBE ANY OTHER CONSTRUCTION EXPERIENCE:

PERSONAL REFERENCE

PHONE NUMBER

I CERTIFY THAT THE INFORMATION GIVEN IN THIS APPLICATION IS TRUE AND ACCURATE.

NAME(SIGNATURE)

Date

Driving Experience

DO YOU HAVE A VALID DRIVER’S LICENSE?

Yes
No

DOES YOUR DIVER’S LICENSE HAVE ANY RESTRICTIONS?

Yes
No

CHECK THE APPROPRIATE EXPERIENCE YOU HAVE WITH COMMERCIAL DRIVING:

1/4 -3/4 TON PICKUP
1 TON PICKUP
TOWING TRAILERS
MED. DUTY TRUCK

CHECK THE APPROPRIATE DRIVERS LICENSE YOU CURRENTLY HOLD:

CLASS R (BASIC)
CDL: CLASS A
CLASS B
CLASS C
HAZ-MAT

HAVE YOU RECEIVED MORE THAN ONE MOVING VIOLATION IN THREE YEARS?

Yes
No

HAVE YOU BEEN INVOLVED IN A TRAFFIC ACCIDENT IN THE PAST THREE YEARS?

Yes
No

WEATHERCRAFT COMPANY IS AN EQUAL OPPORTUNITY EMPLOYER

In order to provide equal employment and advancement opportunities to all individuals, employment decisions at Weathercraft will be based on merit, qualifications, and abilities. Weathercraft does not discriminate in employment opportunities or practices because of race, color, religion, sex, national origin, age, disability political beliefs, or marital or familial status.

Applicants and employees who wish to benefit under an affirmative action program are invited to identify themselves. This information is voluntarily provided. It will be kept confidential, and refusal to provide it will not subject any applicant or employee to any adverse treatment. Nothing shall preclude an employee from informing the company, at a desire time under this program.

YOU MAY ANSWER THE FOLLOWING ON A VOLUNTARY BASIS.
CHECK THOSE YOU WISH TO SHARE:

MINORITY

BLACK
HISPANIC
ASIAN-AMERICAN
INDIAN
OTHER

Untitled

SEX

Male
Female

SPECIAL DISABLED VETERANSPECIAL DISABLED VETERAN

Yes
No

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 Veterans Administration for a disability: (A) rated at thirty percent or more, or (B) rated at ten or twenty percent in the case of a veteran who has been determined under Section 1506 of Title 38 USC to have a serious employment handicap; (2) A person who was discharged or released from active duty because of service-connected disability.

VETERAN OF VIETNAM ERA

Yes
No

A veteran, any part of whose active military, naval or air service was during the period August 5, 1964 through May 7, 1975, who:

(1)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. No veteran may be considered to be a veteran of the Vietnam Era under this paragraph after December 31, 1997.

HANDICAPPED

Yes
No

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 impairment. For purposes of the 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.

MOTOR VEHICLE REPORT – INFORMATION RELEASE

Possession of a valid Colorado Driver’s License is favorable to your consideration for employment. Our insurance provider will determine your eligibility to drive for Weathercraft Company. Completing the authorization form below, allows our insurance provider to obtain and review a Motor Vehicle Report.

I authorize Weathercraft Co. of Colorado Springs, Inc. to obtain my motor vehicle report from CB Insurance, Inc. I understand that this record may contain personal information including, but not limited to, child support payments, alimony payments, as well as, information on driving violations and accidents.

NAME(SIGNATURE)

Date

STATE LICENSED ISSUED

DATE OF BIRTH

CONFIDENTIAL POST JOB OFFER/PRE-PLACEMENT MEDICAL QUESTIONNAIRE TO BE COMPLETED BY ALL PERSONS OFFERED POSITION PRIOR TO STARTING WORK

Job offers are conditioned upon completion of this Medical Questionnaire. This Questionnaire is used to assist us in hiring employees to positions suited to any physical or medical limitations they may have and to establish basic information regarding your physical condition before you begin working. This information will be maintained in a confidential file and will not be used to deny any employment opportunities, except in accordance with applicable law.

In the event your response to these questions raises concerns on our part that you cannot safety perform an essential function of the job you have been conditionally offered, we reserve the right to require medical verification of your ability to perform these functions before you are allowed to begin working. We also reserve the right to withdraw your job offer if further inquiry reveals that you cannot safely perform the essential functions of that job. If you qualify as a “disabled person”, this determination will be made after any reasonable accommodation obligations have been satisfied.

INCOMPLETE OR UNSIGNED QUESTIONNAIRES WILL RESULT IN WITHDRAWAL OF YOUR EMPLOYMENT OFFER. FOR EACH “YES” ANSWER, EXPLAIN YOUR ANSWER AT THE END OF THE QUESTIONNAIRE. IF, FOR ANY REASON, YOU ARE UNCERTAIN OF AN ANSWER, INDICATE SO AND BRIEFLY EXPLAIN WHY.

A. As a result of injury, illness, or other cause, do you have any impairment of:

1. Hands that limit dexterity or your ability to maintain a strong grip or hold objects firmly?

Yes

No

2. Arm, wrist, back, shoulder or other problems which limits normal range of motion, full use or strength of your upper extremities?

Yes

No

3. Ankle, knee, foot, leg, or other problems which limit normal range of motion or your ability to stand, walk, squat, kneel, climb stairs, get into and out of vehicles or equipment, or walk on uneven surfaces?

Yes

No

4. The neck or back which interferes with bending or rotation of your neck, or which interferes with your ability to hold your head in fixed positions for prolonged periods of time?

Yes

No

5. The back which interferes with your ability to bend, twist, or flex your back frequently?

Yes

No

6. The back which interferes with your ability to lift or carry objects on a repetitive basis?

Yes

No

7. The joints resulting from stiff, painful, or swollen joints or broken bones?

Yes

No

8. Vision in either eye that interferes with your ability to read, see at a distance, distinguish colors, or see in dim light?

Yes

No

9. Hearing that interferes with your ability to understand spoken words, hear safety alarms or sirens, or requires you to avoid exposure to excessive noise?

Yes

No

B. As a result of injury, illness or other cause, do you have any impairment which may:

1. Affect your equilibrium or ability to maintain your balance?

Yes

No

2. Alter your normal state of consciousness or cause you to become unconscious?

Yes

No

3. Make it dangerous to work around moving machinery?

Yes

No

4. Prohibit you from driving licensed company vehicles on public highways?

Yes

No

5. Prohibit you from working at heights or in confined spaces?

Yes

No

C. Have you ever:

1. Had fainting spells, loss of consciousness, seizures, or epilepsy?

Yes

No

2. Been treated for shortness of breath, emphysema, or other respiratory problems?

Yes

No

3. Had a heart attack, stroke, other heart or circulatory system disease or failure, or high or low blood pressure?

Yes

No

4. Had an illness which affected your nervous system?

Yes

No

5. Had any kind of back problems or any history of back pain?

Yes

No

6. Had back surgery or been treated for a back condition?

Yes

No

7. Had a rupture or hernia?

Yes

No

8. Received a permanent disability award (including any amount of permanent partial disability) for a job or non-job related accident or illness?

Yes

No

9. Been exposed to hazardous materials or radioactive substances?

Yes

No

D. Are you:

1. Currently taking any prescription medication which has side effects that could cause drowsiness or affect your ability to safely perform job duties? (Note: We are not interested in knowing whether you are taking prescribed medication that does not cause drowsiness or other side effects that could affect job safety.)

Yes

No

2. Allergic to inhalants (dust, etc.) fumes, solvents, gasoline products, or other substances commonly found in the work place in our industry?

Yes

No

E. For first aid purposes

1. Do you have any medical condition that we should know about in order to properly administer first aid to you?
(For example, a floating sternum that would cause us to avoid giving CPR or allergies to common first aid medication)

Yes

No

2. If you are a diabetic or have another medical condition that currently requires special treatment from the Company, please advise.
(For example, if you are required to be off work to undergo kidney dialysis, etc.)

Yes

No

F. Do you have any limitations on your ability to perform the duties or the job you have been conditionally offered?

Yes

No

If “YES”, identify nature of limitations and provide any recommendations you have for accommodations:

LIST THE LETTER AND NUMBER FOR EACH QUESTION YOU MARKED “YES” AND EXPLAIN.

THE ABOVE ANSWERS (PAGES 5 – 6) ARE TRUE AND CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT FALSIFICATIONS, MISREPRESENTATIONS, OR OMISSIONS, DETERMINED TO BE MATERIAL BY THE COMPANY, MAY RESULT IN WITHDRAWAL OF MY CONDITIONAL EMPLOYMENT OFFER OR DISCHARGE REGARDLESS OF HOW OR WHEN DISCOVERED.

NAME(SIGNATURE)

Date
MM slash DD slash YYYY

EMERGENCY INSTRUCTIONS

In case of emergency contact:

Name:

Number:

Relationship:

City/State:

Are there any other emergency instructions, circumstances, medial needs, allergic response or procedure the company should know?

Yes

No

PLEASE LIST BELOW: