Employee Application English We Are An Equal Opportunity EmployerPlease PrintName Last Name First Name Middle Initial Social Security Number Address Street Address City Zip Code Phone NumberWORK EXPERIENCE - LIST MOST RECENT JOB FIRSTFrom To Employer's Name/Address/Telephone Start Pay Last Pay Job Title Reason for Leaving Describe the Work You Did From To Employer's Name/Address/Telephone Start Pay Last Pay Job Title Reason for Leaving Describe the Work You Did From To Employer's Name/Address/Telephone Start Pay Last Pay Job Title Reason for Leaving Describe the Work You Did GENERAL INFORMATIONWhat position are you applying for? Choose an Option Full Time? Part Time? When are you available to start work? Are you willing to work overtime? Yes No Are you at least 18 years old? Yes No If not, can you provide a valid Work Permit, high school diploma, or equivalent? Yes No What languages do you speak, read, or write fluently? If hired, can you verify that you have the legal right to work in the United States? Yes No Do you have any special skills, training, or experience which may help you qualify for this job? Yes No If so, please explain Do you have a reliable means of transportation to get to work? Yes No Are there any times during the week that you are not available to work? Yes No If so, please explain Do any of your relatives work for this company? Yes No If so, who? Have you ever worked for this company before? Yes No If so, when? Have you ever been convicted of a crime, excluding misdemeanors and summary offenses?(NOTE:Conviction will not necessarily disqualify applicant) Yes No If so, please explain How did you find out about this job? CERTIFICATION AND ACKNOWLEDGMENT I certify that the information provided herein is true and correct to the best of my knowledge. I understand that, if employed, falsified statements on this Application for Employment form will be considered grounds for termination. I authorize the company to thoroughly investigate my work experience and any other matters related to my suitability for employment. I further authorize my former employers to disclose to the company any and all information they may have concerning my previous employment. in addition, I hereby release the company, my former employers, and all other persons from any and all claims, demands, or liabilities arising out of, or in any way related to, such disclosure. I acknowledge that, if employed, both the company and I have the right to terminate the employment relationship at any time, with or without cause or advance notice. This employment at will relationship will remain in effect throughout my employment with the company and may not be modified by any oral or implied agreement.Applicant's Signature Date Date MM slash DD slash YYYY PERIODS OF EMPLOYMENT Describe all work experience in detail bagning with your current or most recent jobs, clude my service (dicate rank), beships and job-related volunteer work, applicable. Indicale cuber of employees supervised. Use a separate block to describe each postion or gap in employment, needed, allach additional sheets, vong he same formal as on the application. All information in this section must be completed. Rosunies may be attached to provide scdional Wormelon.1. Name of Present or Last Employer: Address: Your Job Tile: Supervisor's Name: Phone No:FROM: MM slash DD slash YYYY TO: MM slash DD slash YYYY HOURS PER WEEK: YOUR NAME IF DIFFERENT DURING EMPLOYMENTDuties and Responsibilities:Reason For Leaving: 2. Name of Next Previous Employer: Address: Your Job Tile: Supervisor's Name: Phone No:FROM: MM slash DD slash YYYY TO: MM slash DD slash YYYY HOURS PER WEEK: YOUR NAME IF DIFFERENT DURING EMPLOYMENTDuties and Responsibilities:Reason For Leaving: 3. Name of Next Previous Employer: Address: Your Job Tile: Supervisor's Name: Phone No:FROM: MM slash DD slash YYYY TO: MM slash DD slash YYYY HOURS PER WEEK: YOUR NAME IF DIFFERENT DURING EMPLOYMENTDuties and Responsibilities:Reason For Leaving: KNOWLEDGE/SKILLS/ABILITIES (KSAs)List KSAs you possess and believe relevant to the position you seek, such as operating heavy equipment, computer skills, fluency in language(s), etc. EXEMPTION FROM PUBLIC RECORDS DISCLOSUREARE YOU A CURRENT OR FORMER LAW ENFORCEMENT OFFICER, OTHER COVERED EMPLOYEE". OR THE SPOUSE OR CHILD OF ONE, WHOSE INFORMATION IS EXEMPT FROM PUBLIC RECORDS DISCLOSURE UNDER SECTION 119.075(4)(d), FLORIDA STATUTES (FS)? YES NO **Other covered jobs include but are not limited to: correctional and correctional probation officers, firefighters, certain judges, assistant state attorneys, state attorneys, as-sistant and statewide prosecutors, personnel of the Department of Revenue or local governments whose responsibilities include revenue collection and enforcement or child support enforcement, and certain investigators in the Department of Children and Families (see 119.071.F.S.) BACKGROUND INFORMATIONHAVE YOU EVER BEEN CONVICTED OF A FELONY OR A FIRST DEGREE MISDEMEANOR? YES NO If "YES", what charges? Where convicted? Date of Conviction: MM slash DD slash YYYY HAVE YOU EVER PLED NOLO CONTENDERE OR PLED GUILTY TO A CRIME WHICH IS A FELONY OR A FIRST DEGREE MISDEMEANOR? YES NO If "YES", what charges? Where? Date: MM slash DD slash YYYY HAVE YOU EVER HAD THE ADJUDICATION OF GUILT WITHHELD FOR A CRIME WHICH ISA FELONY OR A FIRST DEGREE MISDEMEANOR? YES NO If "YES", what charges? Where? Date: MM slash DD slash YYYY NOTE: A "YES" answer to these questions will not automatically bar you from employment. The nature, Job-relatedness, severity and date of the offense in relation to the position for which you are applying are considered [see §112.011, F.S.) CITIZENSHIP The state of Florida hires only U.S. citizens and lawfully authorized alien workers. You will be required to provide identification and either proof of citizenship or proof of authorization to work in the U.S. 1. ARE YOU A U.S. CITIZEN? YES NO 2, IF NO, ARE YOU LEGALLY AUTHORIZED TO ACCEPT EMPLOYMENT WITH THE SPECIFIC HIRING AUTHORITY TO WHICH YOU ARE APPLYING? YES NO RELATIVESTO YOUR KNOWLEDGE, DO YOU HAVE ANY RELATIVES WORKING IN THIS AGENCY? YES NO SELECTIVE SERVICE SYSTEM REGISTRATION Section 110.1129, Florida Statutes, prohibits the employment of any person who was required to register with the Selective Service System under the U.S. Miliary Selective Service Act, but failed to do so. Additionally. If currently employed by the State, this low prohibits the promotion of such individuals or the subsequent re-hire, once they have separated from the State.IF YOU ARE A MALE BORN ON OR AFTER JANUARY 1,1960, HAVE YOU REGISTERED OR DO YOU HAVE PROOF OF AN EXEMPTION FROM THIS REQUIREMENT (DOCUMENTATION MAY BE REQUIRED)? YES NO N/A CERTIFICATION I am aware that any omissions, falsifications, misstatements, or misrepresentations above may disqualify me for employment consideration and, if I am hired, may be grounds for termination at a later date, I understand that any information I give may be investigated as allowed by law, I consent to the release of Information about my ability, employment history, and fitness for employment by employers, schools, law enforcement agencies, and other Individuals and organizations to investigators, personnel staff, and other authorized employees of Florida state government for employment purposes. This consent shall continue to be effective during my employment !! I am hired. I understand that applications submitted for state employment are public records. I certify that to the best of my knowledge and belief all of the statements contained herein and on any attachments are true, correct, complete, and made in good faith. SIGNATURE: DATE: MM slash DD slash YYYY PA ROOFING AND SHEET METALMIAMIORLANDORALEIGH Employee Name: Date: MM slash DD slash YYYY Social Security #: Height: Weight: 1. Do you now have, or have you ever had, any of the following?Epilepsy Yes No Convulsions, seizures Diabetes Yes No What Medication: Cardiac (heart) disease Yes No Meniscectomy Yes No Innarnmation of cartilage of certain joints e.g. knee Amputation: Yes No Leg, Foot, Arm or Hand Polio (Poliomyelitis) Yes No Cerebral Palsy Yes No Multiple Sclerosis Yes No Parkinson's Disease Yes No Patellectomy Yes No Surgically removed kneecap Total/Partial loss of sight: Yes No In one or both eyes or a partial loss of corrected vision of more than 75 % bilaterally Back or neck injuries Yes No doctor's opinion and resulted in disability over a total of Ruptured cruciate ligament Yes No Hemopilia Yes No Chronic osteomyelitis Yes No Infection in bone Surgical/spontaneous fusion Yes No On a major weight-bearing joint (frozen joint) Hyperinsulinism Yes No Muscular Dystrophy Yes No Thrombophlebitis Yes No Hemialed Intervertebral Disk Yes No Removed intervertebral disk Yes No Or spinal fusion Total deafness Yes No Obesity Yes No (30% or more overweight) 2. Have you previously received workers' compensation for an on-the job injury? Yes No If Yes, please write why, when & where: 3. Have you ever received a disability rating or had one assigned to you by an insurance company or slate/federal agency? Yes No If Yes, state percentage: 4. Have you ever injured or sprained your back? Yes No If Yes, did you have surgery? If you had surgery, please give details: 5. Have you ever injured or sprained your neck? Yes No if Yes, did you have surgery? If you had surgery, please give details: 6. Have you ever Injured/Sprianed your knee? Yes No If Yes, did you have surgery? If you had surgery, please give details: 7. Please list any other type of surgery not mentioned above: Yes No 8. Do you have arthritis? Yes No If Yes, what parts of the body are affected? Are you on medication for arthritis? The infonnation on this form shall not be used to discriminate against a qualified individual with a disabiuty because of the existenc of the disability in regard to the following: job application procedures, hiring, advancement or discharge of the employee; employee compensation; job training and other terms, conditions and privileges of employment. Under penalty of perjury, I declare that I have read the foregoing and that the facts alleged are true to the best of my knowledge and belief. Under penalty of perjury, I declare that I have read the foregoing and that the facts alleged are true to the best of my knowledge and belief.Employee Signature: Date: MM slash DD slash YYYY 4495 35th Street, Orlando, FL 32811 Office (407) 650-9541 Fax: (407) 650-9542 Consent to Obtaining Consumer / Background Checks Please read carefully before signing After carefully reading this Background Check Disclosure and Authorization form, I authorize P & A Roofing & Sheet Metal Inc., to order my background check repart from a background check company. I understand that (P&A) may rely on this authorization to order additional background check reports during and throughout my employment without asking me for my authorization again. I also authorize the following agencies and entities to disclose to the background check company and its agents all information about or concerning me, including but not limited to: my past employers or present employers; learning institutions, including colleges and universities; law enforcement and all other federal, state and local agencies; federal, state and local courts; the military; credit bureaus; testing facilities; motor vehicle record agencies; all other private and public sector repositories of information; and, any other person, organization or agency with any information about or concerning me. This information that can be disclosed to the background check company and its agents including but not limited to; information concerning my employment history, earnings history, education, credit history, motor vehicle history, criminal history, drug test results, military service, professional credential, and all other information requested by the background check company or its agents. I also authorize (P&A) to share the background check reports with its agents. I agree that a facsimile, email pdf, or a photocopy of this form is valid just like the original form. I promise that all my personal information on this form is true and correct and understand that dishonesty will disqualify me from consideration for employment with (P&A), or if I am hired or already work for (P&A) that dishonesty is grounds for immediate termination.I accept the terms and conditions contained within this employment application NO YES Name: SSN: Signature: Drivers Lic # Today's Date: Date of Birth: CommentsThis field is for validation purposes and should be left unchanged.