Operations Employment Application Step 1 of 3 33% Welcome to the CACTX Corporation! Thank-you for your interest and time in filling out this application. Prospective employees will receive consideration without discrimination because of race, creed, color, sex, age, national origin or handicap. This application will be given every consideration, but its receipt does not imply that you will be employed. It will be kept available for current consideration for at least 30 days. Please answer all questions as thoroughly as possible and let us know if you have any questions. Feel free to attach or add any other information relevant to your future performance. Name(Required) First Middle Last Suffix Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Cell Phone(Required)Email(Required) Social Security Number(Required) NCDL # and Class(Required) Mode of transporation to/from work(Required) Points on Driving Record(Required) Are you under 18?(Required) Yes No Are you over 70?(Required) Yes No Eligible for employment in the US(Required) Yes No Who to notify in case of an emergency First Last Emergency Contact Phone Skills & ExperienceThe following skills/equipment are valuable to our business. Please SELECT only those that you have SOLID experience: Line-Striping Machine Single-Axle Dump Truck Diamond Blade Pavement Saw Seal-Coating Machine Tandem-Axle Dump Truck General Carpentry/Forming Hot Crack-Filling Melter Skid-Steer Loader Concrete Finishing Asphalt Roller(s) Mini-Excavator Decorative Concrete Surfacing Asphalt Paving Machine Tractor & Box Scrape Power Spray Paint / Coating Tennis Court Coating Motor-Grader Equipment Street-Print Systems Any additional skills or information that you feel may be helpful to us in considering your application?Able and willing to maintain a phone at your residence should the job require?(Required) Yes No Able and willing to work outdoors regardless of weather conditions?(Required) Yes No Able and willing to work overtime/weekends/holidays if the job requires?(Required) Yes No Able and willing to obtain a Class A driver’s license should the job require?(Required) Yes No Able and willing to purchase basic tools and toolbox if needed in your work?(Required) Yes No Able and willing to occasionally travel out-of-town should the job require?(Required) Yes No Allergic to any chemicals? Yes No Please explain Have you ever been disciplined or fired?(Required) Yes No Please explain Have you ever been convicted of a crime?(Required) Yes No Please explain Does your present physical health allow you to do asphalt and concrete work?(Required) Yes No Have you missed any work in the past twelve months due to illness/injury?(Required) Yes No How did you learn of our organization? Personal ReferencesTwo references excluding relatives or former employers.Name(Required) Address(Required) Occupation(Required) Day Phone(Required) Evening Phone(Required) Name Address Occupation Day Phone Evening Phone Prior EmploymentCompany Name(Required) Address(Required) Phone(Required)Supervisor Name(Required) Your Job Title(Required) Reason for Leaving(Required) Start Date(Required) End Date(Required) Starting Wage/Salary(Required) Final Wage/Salary(Required) Company Name Address Phone Supervisor Name Your Job Title Reason for Leaving Start Date End Date Starting Wage/Salary Final Wage/Salary Company Name Address Phone Supervisor Name Your Job Title Reason for Leaving Start Date End Date Starting Wage/Salary Final Wage/Salary EducationGrammar School Name Location (City, State) High School Name Location (City, State) Last Grade Completed Diploma/Degree Obtained Yes No College/Trade School Name Location (City, State) Years Completed Diploma/Degree Obtained Yes No Background Checks and TestingAs a condition of employment will you agree to a background investigation?(Required) Yes No As a condition of employment will you agree to drug testing?(Required) Yes No In the event of employment, I will furnish proof of my identity, proof of U. S. Citizenship or any other proof needed to accept such employment. I certify that all statements I have made in this application are true and agree that any false statements or omission of facts may result in cancellation of my application for employment or immediate dismissal. I understand that to begin this job I must meet the full physical requirements of the position. I also understand that the company cannot guarantee work hours or permanent employment.Signature(Required)NameThis field is for validation purposes and should be left unchanged.