717.938.1468
Wes Hannon

Employment Application

LEON E. WINTERMYER, INC.

APPLICATION FOR EMPLOYMENT

EQUAL OPPORTUNITY EMPLOYER

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, or non-job related disability.

Position(s) Applied For Date of Application

Have you lived at this address for three years or more?

Previous Address
Did you live at this address for three years or more?
Telephone Number(s)
Other Name(s) under which you attended school or were employed

How did you learn about our company?

If you are under 18 years of age, can you provide proof of your eligibility to work?  Yes No
**Note: Proof of citizenship or immigration status will be required upon employment. (An I-9 form must be completed.)
Have you ever filed an application with us before? If yes, when?
Have you worked for LEW, Inc. before? If yes, when?
Are you currently employed?
Are you currently on “lay-off” status and subject to recall?

Have you ever been convicted of or pled guilty or no contest to a misdemeanor or a felony? (An affirmative answer will not necessarily preclude employment.)

If yes, give date, place, charge and disposition
**Note: A criminal background check may be conducted by the Pennsylvania State Police as required by Act 34. Employees may be required to complete Pennsylvania Child Abuse History Clearance Forms as required by Act 151.
Do you have any limitations regarding hours that you can work?
If yes, explain
Do you have any travel restrictions?
If yes, list and explain
Do you have transportation available?
Do you have friends or relatives employed at LEW, Inc.
If yes, list names
When are you available for work?
Do you have a current:
First Aid Certification Expiration Date Certifying Agency
CPR Certification Expiration Date Certifying Agency
OSHA 10 Hour Construction Safety Certification

Education

Name & Address of School Course of Study Years Completed Diploma/Degree
High School or GED
College
Trade School
Apprenticeship
Military
Correspondence
Other (Specify)

U.S. Military Service

Branch of ServiceLength of Service Rank/Rate at Discharge

Are you a member of the Armed Services Reserve?


Do you have a current Driver’s License? (State # Class Exp. Date )

List all accidents and moving violations (other than parking) for the past 3 years. Include a description of any fatalities or injuries arising from any accidents.


**Note to Applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB(S) FOR WHICH YOU ARE APPLYING.

Are you fully able, with or without reasonable accommodation, to perform the essential functions of the job(s) for which you are applying?

Describe how you would perform the job with or without a reasonable accommodation

Employment Experience (If you need additional space, please continue on a separate piece of paper.)

Start with your present or most recent job. Include and complete fully all employment, including any job-related military service assignments and volunteer activities. You may exclude organizations which indicate age, race, color, religion, gender, national origin, disability or other protected status. All applicants to drive a commercial motor vehicle in intrastate or interstate commerce must provide information on all employers for whom the applicant operated such vehicle during the past ten years.


















































































































































































Name Of Employer

Address (City & State)

Area Code/Telephone

Date Started

Starting Salary/Wage

Starting Position

May We Call You At This Number?

Date Stopped

Ending Salary/Wage

Position At Time Of Leaving

May We Contact Your Present Employer Prior To

Any Employment Offer?

Name & Title Of Supervisor

Reason For Leaving

Brief Description Of Your Responsibilities
Name Of Employer Address (City & State) Area Code/Telephone
Date Started Starting Salary/Wage Starting Position
Date Stopped Ending Salary/Wage Position At Time Of Leaving
Name & Title Of Supervisor Reason For Leaving
Brief Description Of Your Responsibilities
Name Of Employer Address (City & State) Area Code/Telephone
Date Started Starting Salary/Wage Starting Position
Date Stopped Ending Salary/Wage Position At Time Of Leaving
Name & Title Of Supervisor Reason For Leaving
Brief Description Of Your Responsibilities
Name Of Employer Address (City & State) Area Code/Telephone
Date Started Starting Salary/Wage Starting Position
Date Stopped Ending Salary/Wage Position At Time Of Leaving
Name & Title Of Supervisor Reason For Leaving
Brief Description Of Your Responsibilities

Comments (including explanation of any gaps in employment)

List professional, trade, business civic activities and offices held. (You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status)
































References

Do not list relatives or employers

Name

Address

Telephone


Important Authorization and Understanding

  1. Completeness and accuracy of information. I represent that all of the information now or hereafter given by me in support of my application for employment is true and complete. I understand that, if I am hired, any false or misleading information in support of my application may subject me to discharge at any time during the period of my employment.
  2. Authorization for release of information and release from liability. I authorize you to verify any of the information given during the application process with appropriate individuals, companies, or agencies, and I authorize them to release such information as you require, including my prior disciplinary employment record, without any obligation to give me written notice of disclosure. I hereby release you and them from any liability whatsoever as a result of such inquiries and disclosures. A photocopy or other electronic reproduction of this authorization/release is binding, and may be relied upon.
  3. Employment is at will. I understand that if I am employed, I will be an employee at will. This means that either the employer or the employee may terminate the employment relationship with or without cause at any time.
  4. No written, oral, or implied contracts. I understand that any written Company documents, oral statements, or formal or informal policies are not to be construed as granting an express or implied employment contract and that I am not entitled to rely upon any such documents, statements or Company policies as stating employment terms. The employment relationship with the Company may be modified only in writing directed to me by the President of the Company.
  5. Benefits may be altered. I understand that the Company at its option may change, delete, suspend, or discontinue any part or parts of its benefit program at any time without prior notice, both while person are actively employed and while retired or otherwise separated from employment with the Company.
  6. I understand that a test for drug and alcohol misuse may be required as part of the interview process, and I hereby authorize the release of test results to the Company. I hereby consent to the performance of such medical examination and testing. I waive all claims arising out of these procedures against the Company and those performing the examination and tests. I understand and consent that as a condition of continued employment, I will submit to drug and alcohol testing in the future. I authorize the release of any such subsequent testing to the Company and waive all claims against it or those performing the examination and tests. I understand that I will be subject to immediate termination for failing to submit to examination or testing.
  7. If an employment relationship is established, I agree to wear or use all protective clothing or devices as may be required by the Company and to comply with all safety policies and procedures.

I acknowledge that I have read and understand the above statement in its entirety, and have had the opportunity to ask questions regarding any aspect of this application, and that I accept the above terms.










Signature Date

EEO CARD


This is a record that will help us comply with the Equal Employment Opportunity Commission in submitting certain required reports and to monitor Leon E. Wintermyer, Inc.’s Affirmative Action program in accordance with Title VII of the Civil Rights Act of 1964 (as amended by the Equal Employment Opportunity Act of 19720 will be kept separate from the personnel file and other records used for personnel decisions.


In order to ensure equal opportunity for all persons, APPLICANTS ARE REQUESTED, BUT NOT REQUIRED, to answer the questions listed below.


* * * * * * * * * * * * * * * *


NAME:

Race:

Sex:

DATE OF BIRTH:

PHYSICAL OR MENTAL HANDICAP?:

A “Handicapped Individual” is any person who (1) has a physical or mental impairment which substantially limits one or more major life activities, (2) has a record of such impairment, or (3) is regarded as having such an impairment.

If you checked “Yes” above, please suggest accommodation you feel might be necessary for your employment:

DISABLED VETERAN?

A “Disabled Veteran” is an individual entitled to disability compensation under the laws administered by the Veterans Administration for a disability rated at 30 percent or more, or a person whose discharge or release from active duty was due to a disability incurred or aggraved in the line of duty.

VETERAN OF THE VIETNAM ERA?

A “Vietnam Era Veteran’ is an individual who (1) served on active duty for a period of more than 180 days, any part of which occurred between August 5, 1964 and May 7, 1975, and was discharged or released therefrom with other than a dishonorable discharge, or (2) any part of such active duty was performed between August 5, 1964 and May 7, 1975.

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54.92.194.75

United States