Non-DOT Application Form

Applicant to Complete

Position Applied For*

Today's Date*

Phone

First Name*

Middle Initial*

Last Name*

Current Address:

Street Address*

Address Line 2

City*

State*

Zip Code*

Email Address*

Social Security Number

Do you have the legal right to work in the United States?*
YesNo

Are you 18 years of age or older?*
YesNo

Have you worked for this company before?*
YesNo

If yes, state when, where, what projects you worked on, and with whom.

List any friends or relatives other than spouse working for us.

Select the option that represents the highest level of completed educational background.*
High SchoolGEDTrade/Business SchoolCollegeOther

If you selected "Other" from the options above, please specify:

Enter School Information:

List any special qualifications, licenses, or other information which may help you qualify for the position.

List any equipment or machinery you can operate.

Employment History

Current or Last Employer*

May we contact?*
YesNo

If yes, provide phone number:

Reason for leaving*

Next Previous Employer

May we contact?*
YesNo

If yes, provide phone number:

Reason for leaving*

Next Previous Employer

May we contact?*
YesNo

If yes, provide phone number:

Reason for leaving*

References

List two people not related to you whom you have known for at least 1 year.*

Applicant Certification and Agreement

I certify that the facts set forth in this Employment Application are true and complete to the best of my knowledge. I understand that falsification, omissions or misstatements may prevent my being hired, or if already hired, may subject me to dismissal. I authorized Park Construction Company to make a thorough investigation of my entire work history, and to verify all data given in my application for employment. I release from liability any person giving or receiving information regarding my personal history, medical information and prior work record. I understand and agree that my employment is for no definite period of time and may be terminated by this company at any time without liability for wages or salary except such as may have been earned at the date of termination. I understand that, if hired, I will abide by all the rules and regulations of Park Construction Company.

Please note, you must check the box below in order to be able to submit your application:

I accept

I (Name) accept the terms above.

First Name*

Last Name*

Today's Date*

Federal and state laws and regulations prohibit discrimination in employment because of race, color, sex, religion, national origin, age, ancestry, creed, affectional preference, marital status, sexual orientation, status with regard to public assistance, physical or mental handicap, or disabled veteran status.

Affirmative Action Survey

As an employer/government contractor, we must comply with government regulations and affirmative action responsibilities. The information requested below will be used to determine if our recruitment efforts are reaching all segments of the community and will meet our reporting requirements. The information will be used and kept confidential in accordance with the applicable laws and regulations, including those that require the information to be summarized and reported to the Federal Government for Civil Rights enforcement. When reported, the data will not identify any specific individual. This information is voluntary.

First Name

Middle Initial

Last Name

Check one:
MaleFemaleI choose not to declare

Ethnicity
African-AmericanAmerican Indian/Native AlaskanAsian/Pacific IslanderCaucasianHispanicMore than oneI choose not to declare

Definitions of race/ethnic categories:

• Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.

• White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

• Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa.

• Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

• Asian (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

• American Indian or Alaska Native (Not Hispanic or Latino) - A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.

• Two or More Races (Not Hispanic or Latino) - All persons who identify with more than one of the above five races.

Voluntary Self-Identification of Disability
Yes, I have a disability, or have had one in the pastNo, I do not have a disability and have not had one in the pastI choose not to declare

How do you know if you have a disability?

A disability is a condition that substantially limits one or more of your “major life activities.” If you have or have ever had such a condition, you are a person with a disability. Disabilities include, but are not limited to:

• Alcohol or other substance use disorder (not currently using drugs illegally)

• Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, HIV/AIDS

• Blind or low vision

• Cancer (past or present)

• Cardiovascular or heart disease

• Celiac disease

• Cerebral palsy

• Deaf or serious difficulty hearing

• Diabetes

• Disfigurement, for example, disfigurement caused by burns, wounds, accidents, or congenital disorders

• Epilepsy or other seizure disorder

• Gastrointestinal disorders, for example, Crohn's Disease, irritable bowel syndrome

• Intellectual or developmental disability

• Mental health conditions, for example, depression, bipolar disorder, anxiety disorder, schizophrenia, PTSD

• Missing limbs or partially missing limbs

• Mobility impairment, benefiting from the use of a wheelchair, scooter, walker, leg brace(s) and/or other supports

• Nervous system condition, for example, migraine headaches, Parkinson’s disease, multiple sclerosis (MS)

• Neurodivergence, for example, attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder, dyslexia, dyspraxia, other learning disabilities

• Partial or complete paralysis (any cause)

• Pulmonary or respiratory conditions, for example, tuberculosis, asthma, emphysema

• Short stature (dwarfism)

• Traumatic brain injury

Military Veteran (select all that apply)

Not a VeteranRecently Separated VeteranVietnam Era VeteranWar/Campaign/Expedition VeteranArmed Forces Service Medal VeteranI choose not to declare

Military Branch and Rank

Referral Source (select all that apply)
Employment AgencyCommunity AgencyNewspaper AdOnline ApplicationPark EmployeeJob ServiceCollege RelationsRehireUnion Hall

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