Application for Employment

We are an equal opportunity employer. We comply with all applicable Federal, State and Local laws concerning discrimination in employment. No question in this application is intended to elicit information in violation of any such law nor will any information obtained in response to any question be used in violation of any such law.

Complete the form below to apply.

Position(s) Applied For

Date of Application

APPLICANT INFORMATION
Last Name	First Name	Middle Name
Street Address	City and State	Zip
Home Phone	Mobile/Pager/Other	Social Security Number

Email address:

If you are under 18, and required, can you furnish a work permit?

Yes No

If No, please explain

Have you been employed here before?

Yes No

Are you legally eligible for employment in this country?

Yes No

Date available for work

/ 2001

Type of employment desired

Are you able to meet the attendance requirements of the position?

Yes No

Have you been convicted of a crime in the last seven (7) years?

If Yes, please explain

Yes No

Driver's license number if driving is an essential job function

State

WORK EXPERIENCE

Current Employer (or most recent)

Dates of Employment

From To

Employer

Address

Phone

Job Title

Immediate Supervisor and Title

Nature of work performed and job responsibilities

Reason for leaving

Hourly Rate/Salary

Final $ per

Previous Employment (prior to above)

Dates of Employment

From To

Employer

Address

Phone

Job Title

Immediate Supervisor and Title

Nature of work performed and job responsibilities

Reason for leaving

Hourly Rate/Salary

Final $ per

Previous Employment (prior to above)

Dates of Employment

From To

Employer

Address

Phone

Job Title

Immediate Supervisor and Title

Nature of work performed and job responsibilities

Reason for leaving

Hourly Rate/Salary

Final $ per

Previous Employment (prior to above)

Dates of Employment

From To

Employer

Address

Phone

Job Title

Immediate Supervisor and Title

Nature of work performed and job responsibilities

Reason for leaving

Hourly Rate/Salary

Final $ per

SKILLS AND QUALIFICATIONS

Summarize any training, skills, licenses, and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying

RECORD OF EDUCATION (IF JOB RELATED)

High School

College

Other

PERSONAL REFERENCES

NAME

PHONE

YEARS KNOWN

TO BE COMPLETED BY ALL APPLICANT'S - PLEASE READ CAREFULLY BEFORE SIGNING I certify that the information contained in this application and in any resume provided by me or any party representing my interests is correct and complete to the best of my knowledge. I understand that any false statements, misrepresentations or omissions made by me on this application or any supplement thereto, will be sufficient grounds for rejection of this application or discharge after employment. I give the employer the right to obtain pertinent information concerning me from former employers and others, and I release all those providing or requesting such information from any liability that may arise by truthful disclosures or such investigations. If I am hired, I understand that I am free to resign at any time with or without cause and without prior notice and the employer reserves the same right to terminate my employment at any time with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no representative of the employer, other than an authorized officer, has the authority to make any assurances to the contrary. I further understand that any such assurances must be in writing and signed by an authorized officer. I understand it is the company's policy not to refuse to hire a qualified individual with a disability because of that persons's need for a reasonable accommodation as required by the I also understand that if I'm hired, I will be required to provide proof of identity and legal work authorization.

Applicant's Name Date

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Central States Roofing Company

Central States Roofing is Colorado Springs oldest commercial roofing contractor and Colorado Springs only commercial roofing company to use highly skilled union labor.

5925 Omaha Blvd.
Colorado Springs, CO 80916

(719) 570-1774 Fax: (719) 570-7013

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