Ron Perrin
Water Technologies EMPLOYMENT APPLICATION
PO Box 101614
Fort Worth, Texas 76185
Phone 1-888-481-1768 Email FAX (817) 246-1740
- Name:______
Last First Middle
2.Address:______Number Street
3. ______
City State Zip code
4. Telephone Number: ( )______Cell Number: ( )______
5. Date of Birth: ______/______/______
Month Day Year
6. Social Security Number: ______
7. Are you a U.S. citizen? ______
Yes No
8. Drivers License Number and State: ______
9. Height (Ft & Inches):______Weight (pounds): ______
10. EMERGENCY CONTACT INFORMATION:
Name______Phone______
Address______Cell Phone______
______Relationship?______
A.Work History – Beginning with your present or most recent job, list all employment for the previous 3 years. Attach extra pages if necessary.
1. From: ______to ______Employer:______
Address: ______
Phone: ______Job title: ______
Duties: ______
Supervisor: ______name of Co-worker: ______
Reason for leaving: ______
2. From: ______to ______Employer:______
Address: ______
Phone: ______Job title: ______
Duties: ______
Supervisor: ______name of Co-worker: ______
Reason for leaving: ______
3. From: ______to ______Employer:______
Address: ______
Phone: ______Job title: ______
Duties: ______
Supervisor: ______name of Co-worker: ______
Reason for leaving: ______
4. From: ______to ______Employer:______
Address: ______
Phone: ______Job title: ______
Duties: ______
Supervisor: ______name of Co-worker: ______
Reason for leaving: ______
5. From: ______to ______Employer:______
Address: ______
Phone: ______Job title: ______
Duties: ______
Supervisor: ______name of Co-worker: ______
Reason for leaving: ______
B.Educational History –
1. High Schools City & State From To Graduated
Attended Yes No
______
______
______
2. A. College or University Attended: ______
City & State: ______dates attended: ______
Units completed: ______Major / Minor: ______
Degree received , if any, and date: ______
B. College or University Attended: ______
City & State: ______dates attended: ______
Units completed: ______Major / Minor: ______
Degree received , if any, and date: ______
C. College or University Attended: ______
City & State: ______dates attended: ______
Units completed: ______Major / Minor: ______
Degree received , if any, and date: ______
3. List other schools attended (trade, vocational, business, etc.) Give name and address of school , dates attended, course of study, certificate, and any other pertinent information. (copies of certifications will suffice).
C.SPECIAL QUALIFICATIONS AND SKILLS
1.List any special licenses you hold (such as API, scuba, etc.). Show licensing authority, original date of issue, and date of expiration.
______
______
______
2.List any specialized machinery or equipment which you can operate.
______
______
D. ARRESTS, DETENTIONS AND LITIGATION
1.Have you ever been arrested for DWI
Yes ______No ______
E. Traffic Record – This job requires a lot of drive time in a company truck.
1.Has your drivers license ever been suspended or revoked?
Yes ______No ______
If yes, give date, location and reasons. ______
______
2.With what company do you carry auto insurance? ______
3.List to the best of your memory all traffic citations you have received, excluding parking tickets.
Month & Year Charge City & State Disposition
______
______
______
______
______
______
4.Describe in a brief narrative any traffic accidents in which you have been involved, giving approximate dates and locations.
______
______
______
______
______
F. Medical History Climbing 150’ Ladders requires good health, and that you are physically fit.
1.List the following information concerning all doctors consulted within the last 3 years and all periods of hospitalization within the past 5 years.
Reason(s) Month & year # of days Physician and or Hospital
______
______
______
______
2.Do you have any physical handicaps, chronic diseases or disabilities?
Yes______No ______
If yes, explain. ______
______
3.Have you ever received workman's compensation or any other disability insurance payments?
Yes ______No ______
If yes, explain.
______
______
4.Are you currently taking any medication prescribed by your physician that would effect you
working in high places?
Yes ______No ______
If yes, explain.
______
______
D.REFERENCES - List 3 persons who know you well enough to provide current information about you. Do not list relatives or former employers.
Name: ______Address: ______
Home Phone: ______Work Phone: ______
Business address: ______
Years Known: ______
Name: ______Address: ______
Home Phone: ______Work Phone: ______
Business address: ______
Years Known: ______
Name: ______Address: ______
Home Phone: ______Work Phone: ______
Business address: ______
Years Known: ______
I hereby certify that there are no willful misrepresentations, omissions or falsifications in the forgoing statements and answers to questions. I am fully aware that any such willful misrepresentations, omissions or falsifications may be grounds for immediate rejection or termination of employment.
______
Signature of applicant date
Be sure to check out my web site for additional information.
Look forward to hearing from you
Ron Perrin
www.ronperrin.com
A day at the office: Are you sure your ready?