Application for Employment
Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department.

Position(s) applied for Date of application (MM/DD/YYYY)
Last Name First Name Middle Name Social Security #
Address City State Zip Code
Telephone # Mobile/Beeper/Other # E-mail Address
Referral Source (How did you hear about us?)
If you are under 18, and it is required, can you furnish a work permit? Yes No
If no, please explain:
Have you ever been employed here before? Yes No
If yes, give dates and positions:
Are you legally eligible for employment in this country? Yes No
Date available for work (MM/DD/YYYY) What is your desired salary range?
Type of employment desired Full-Time Part-Time Temporary Seasonal Educational Co-Op
Driver's license number if driving may be required in position for which you are applying State
Date of Birth
1. Have you ever been denied a driver's license or had one suspended or revoked? Yes No
2. Have you had any violations in the past 5 years? Yes No
3. Have you had any auto accidents in the past 5 years? Yes No
If the answer to any question was "Yes", please explain (give dates of violations and/or accidents)
Answering "yes" to the following question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account
Have you ever pled "guilty" or "no contest" to, or been convicted of a crime Yes No
If yes, please provide date(s) and details
Employment History
Employer Telephone # Date employed (MM/YYYY)
to
Address City State
Starting job title/final job title
Immediate supervisor and title (for most recent position held) May we contact for reference?
Yes No Later
Why did you leave?
Summarize the type of work performed and job responsibilities
What did you like most about your position?
What were the things you liked least about the position?
Compensation (Starting) Compensation (Final)
Hourly Salary $ per
Commission/Bonus/other Compensation $ 		Hourly Salary $ per
Commission/Bonus/other Compensation $
Employer Telephone # Date employed (MM/YYYY)
to
Address City State
Starting job title/final job title
Immediate supervisor and title (for most recent position held) May we contact for reference?
Yes No Later
Why did you leave?
Summarize the type of work performed and job responsibilities
What did you like most about your position?
What were the things you liked least about the position?
Compensation (Starting) Compensation (Final)
Hourly Salary $ per
Commission/Bonus/other Compensation $ 		Hourly Salary $ per
Commission/Bonus/other Compensation $
Employer Telephone # Date employed (MM/YYYY)
to
Address City State
Starting job title/final job title
Immediate supervisor and title (for most recent position held) May we contact for reference?
Yes No Later
Why did you leave?
Summarize the type of work performed and job responsibilities
What did you like most about your position?
What were the things you liked least about the position?
Compensation (Starting) Compensation (Final)
Hourly Salary $ per
Commission/Bonus/other Compensation $ 		Hourly Salary $ per
Commission/Bonus/other Compensation $
Skills and qualifications
Summarize any special training, skills, licenses and/or certificates that may assist you in performing the position for which you are applying
Trade Licenses (Check appropriate boxes. Include license number and years experience.)
Linc Master HVAC Years
Linc Journeyman HVAC Years
Linc Apprentice HVAC Years
Refrigeration Card Years
NATE Years
Linc Master Plumber Years
Linc Journeyman Plumber Years
Linc Apprentice Plumber Years
Linc Master Gas fitter Years
Linc Journeyman Gas fitter Years
Linc Apprentice Gas fitter Years
Nebr Grade 6 Operator Years
Equipment Skills
Forklift Years
Bobcat Years
Scissor Lift Years
Backhoe Years
Trailer Years
Other
Please specify: 		Years
Educational Background
School (Include City and State) Years Completed Completed GPA
class rank		 Major/Minor
References
Name Title Relationship to you Telephone Number of
years known
Applicant Statement

I certify that all information I have provided in order to apply for and secure work with this employer is true, complete and correct.

I expressly authorize, without reservation, the employer its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state or federal law.

I understand that this application remains current for only 14 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement of contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express languages are valid unless they are in writing and signed by the employer's president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in that regard.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer's service, whenever it is discovered.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.
I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.
To accept the Applicant Statement, type "agree" Date (MM/DD/YYYY)

Green Furnace & Plumbing Co., Inc
4200 N. 48th Street, Lincoln, NE 68504
402-467-4444
Fax: 402-467-4675