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Emerald Coast Striping

EMERALD COAST STRIPING

1901 East Ave Panama City, FL 32405

8840 Fowler Ave Pensacola, FL 32534

4454 Entrepot Blvd Tallahassee, FL 32310

4826 Airport Rd Zephyrhills, FL 32542

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Apply for A Position with Us

EMPLOYMENT APPLICATION FORM

APPLICANT LOG Emerald Coast Striping, LLC is an Equal Opportunity Employer. The Federal Government requires us to monitor and be able to produce data pertaining to the sex, ethnic background, citizenship and veteran status of our job applicants. Completing the following Applicant Log information is voluntary. It will be removed from the Application and not forwarded to any employing department or to any Placement Specialists reviewing your application. In keeping with company's status as an Equal Opportunity Employer, this information will not be used in making any decision affecting hiring or any personnel action following employment. If you prefer not to complete any section of this form, you may leave it blank. Should you accept an employment offer, you are then required to provide the requested birth date, sex, ethnic and citizenship information.

Emerald Coast Striping, LLC is an Equal Opportunity Employer. The Federal Government requires us to monitor and be able to produce data pertaining to the sex, ethnic background, citizenship and veteran status of our job applicants.

APPLICATION FOR EMPLOYMENT APPLICANTS MAY BE TESTED FOR ILLEGAL DRUG

APPLICANTS MAY BE TESTED FOR ILLEGAL DRUGS

DATE

Last Name

First Name

Middle Name

Maiden Name

Present Address Number

Present Address Street

Present Address City

State

Zip

Social Security No.

How long have you lived at current address?

Home Telephone

Cell Telephone

If Under 18, please list age

What position are you applying for?

What is the desired salary? (Be specific)

Days available to work (check all that apply)

No preference

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

What hours are you available?

How many hours can you work weekly?

Employment desired

FULL TIME ONLY

PART TIME ONLY

FULL OR PART TIME

Date available to begin work?

NAME OF SCHOOL (High School)

LOCATION (Complete Mailing Address) (High School))

NUMBER OF YEARS COMPLETED (High School)

MAJOR & DEGREE (High School)

NAME OF SCHOOL (College)

LOCATION (Complete Mailing Address) (College)

NUMBER OF YEARS COMPLETED (College)

MAJOR & DEGREE (College)

NAME OF SCHOOL (Bus. Or Trade School)

LOCATION (Complete Mailing Address) (Bus. Or Trade School)

NUMBER OF YEARS COMPLETED (Bus. Or Trade School)

MAJOR & DEGREE (Bus. Or Trade School)

NAME OF SCHOOL (Professional School)

LOCATION (Complete Mailing Address) (Professional School)

NUMBER OF YEARS COMPLETED (Professional School)

MAJOR & DEGREE (Professional School)

HAVE YOU EVER BEEN CONVICTED OF A CRIME?

No

Yes

If yes, explain number of conviction(s), nature of offense(s) leading to convictions(s), how recently such offense(s) was/were committed, sentence(s) imposed and type(s) of rehabilitation.

DO YOU HAVE A DRIVERS LICENSE?

Yes

No

What is your means of transportation to work?

Drivers' License number

State of issue

Expiration Date

Operator

Commercial (CDL)

Have you had any accidents during the past three years?

How Many

Have you had any moving violations during the past three years?

How Many

Please list two references other than relatives or previous employers.

Please list two references other than relatives or previous employers.

Reference Name #1

Position

Company

Telephone

Address

Reference Name #1

Position

Company

Telephone

Address

An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying.

An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying.

MILITARY

MILITARY

HAVE YOU EVER BEEN IN THE ARMED FORCES?

Yes

No

ARE YOU A MEMBER OF THE NATIONAL GUARD

Yes

No

Specialty

Date Entered

Discharge Date

Work

Work Experience

Please list your work experience for the past five years beginning with your most recent job held.

Please list your work experience for the past five years beginning with your most recent job held.

If you were self-employed, give firm name. Attach additional sheets if necessary.

If you were self-employed, give firm name. Attach additional sheets if necessary.

Name of Employer

Address

City, State, Zip Code

Phone Number

Name of last supervisor

Employment Dates

Pay or Salary

Your last job title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

Name of Employer

Address

City, State, Zip Code

Phone Number

Name of last supervisor

Employment Dates

Pay or Salary

Your last job title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

Name of Employer

Address

City, State, Zip Code

Phone Number

Name of last supervisor

Employment Dates

Pay or Salary

Your last job title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

Name of Employer

Address

City, State, Zip Code

Phone Number

Name of last supervisor

Employment Dates

Pay or Salary

Your last job title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

May we contact your present employer?

Yes

No

Did you complete this application yourself

Yes

No

If not, who did?

Free Text

Completing the following Applicant Log information is voluntary. It will be removed from the Application and not forwarded to any employing department or to any Placement Specialists reviewing your application. In keeping with company's status as an Equal Opportunity Employer, this information will not be used in making any decision affecting hiring or any personnel action following employment. If you prefer not to complete any section of this form, you may leave it blank.

Should you accept an employment offer, you are then required to provide the requested birth date, sex, ethnic and citizenship information.

LAST NAME

FIRST NAME

MIDDLE/MAIDEN NAME

SOCIAL SECURITY NUMBER

BIRTH DATE

CITIZENSHIP

C-U.S.CITIZEN

R-RESIDENT FOREIGN NATIONAL An alien who has admitted for permanent residence (must have Alien Registration Receipt Card, Form I-551)

N-NON-RESIDENT FOREIGN NATIONAL

ETHNIC BACKGROUND

1-WHITE (not Hispanic: Origins in Europe, North Africa or the middle East.

2-BLACK (not Hispanic): Origins in any of the black racial groups.

3-AMERICAN INDIAN or ALASKAN NATIVE: Origins in the original peoples of North America

4-ASIAN or PACIFIC ISLANDERS: Origins in the Far East, Southeast Asia, the Indian subcontinent or the Pacific Islands

5-HISPANIC; Mexicans, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin regardless of race.

SEX

M-Male

F-Female

VETERAN STATUS

V-VIETNAM ERA VETERAN (08-05-1964 to 05-07-1975): "A person (1) who (i) served on active duty for a period of more than 180 days, any part of which occurred during the Vietnam era, and was discharged or released therefrom with other than a dishonorable discharge, or (II) was discharged for a service connected disability if any part of such active duty was performed during the Vietnam era, and (2) who was so discharged and released within 48 months preceding his application for employment under the Act"

THIS APPLICATION IS IN RESPONSE TO (please specify one)

N1-News Herald Newspaper

N6-Another Newspaper or Professional Publication (please specify):

ES-Employment Security Commission

P-Personal Referral

R-Radio

TV-Television

Electronic/INTERNET/INFO

O-Other (please specify):

Please Specify:

HIRING MEDICAL QUESTIONNAIRE

HIRING MEDICAL QUESTIONNAIRE

This questionnaire is solely for the purpose of providing us with information. The questionnaire is not being used as the basis for deciding whether to employ you.

This questionnaire is solely for the purpose of providing us with information. The questionnaire is not being used as the basis for deciding whether to employ you.

Name

Height

Weight

Soc. Sec.#

Drivers' License

Telephone

Instructions: Answer YES or NO to the following questions. If your answer is YES list the approximate date of injury or treatment and give the details (doctor, hospital, etc.) in the space for details after the last questions. Be sure to number your responses if you answered YES to more than one question. Do not skip any questions.

Instructions: Answer YES or NO to the following questions. If your answer is YES list the approximate date of injury or treatment and give the details (doctor, hospital, etc.) in the space for details after the last questions. Be sure to number your responses if you answered YES to more than one question. Do not skip any questions.

1. Have you ever had a back injury?

When?

2. Have you ever had a herniated disc in your back?

When?

3. Have you ever had back surgery for removal of a disc?

When?

4. Have you ever had a neck injury?

When?

5. Have you ever had a herniated disc in you neck?

When?

6. Have you ever had neck surgery for removal of a disc?

When?

7. Have you ever had a knee injury?

When?

8. Have you ever had surgery on either of your knees?

When?

9. Have you ever had surgery on either of your shoulders?

When?

10. Have you ever had an elbow injury?

When?

Which elbow?

11. Have you ever had surgery on either of you elbows?

When?

Which elbow?

12. Do you have or have you ever had an amputation of your foot, leg, arm or hand?

When?

13. Do you have or have you ever had epilepsy?

When?

14. Do you have or have you ever had diabetes?

When?

15. Do you have or have you ever had cardiac disease? (Hearth Trouble)?

When?

16. Do you have or have you ever had total loss of sight of one or both eyes or a partial loss of corrected vision of more than 75 percent bilaterally?

When?

17. Do you have or have you ever had cerebral palsy?

When?

18. Do you have or have you ever had multiple sclerosis?

When?

19. Do you have or have you ever had Parkinson's disease?

When?

20. Do you have or have you ever had vascular disorder?

When?

21. Do you have or have you ever had psychoneurotic disability following treatment in a recognized medical or mental institution for a period in excess of 6 months?

When?

22. Do you have or have you ever had muscular dystrophy?

When?

23. Do you have or have you ever had loss of hearing?

When?

24. Do you have or have you ever had mental retardation?

When?

25. Do you have or have you ever had any physical or mental condition which you believe may be permanent?

Briefly describe the condition

26. Do you have or have you ever had high blood pressure?

When?

27. Do you have or have you ever had varicose veins or leg ulcer?

When?

28. Do you have or have you ever had tuberculosis?

When?

29. Do you have or have you ever had allergies or asthma?

When?

30. Do you have or have you ever had skin trouble?

When?

31. Do you have or have you ever had reaction to serum or drugs?

When?

32. Do you have or have you ever had kidney or bladder trouble?

When?

33. Do you have or have you ever had ulcers?

When?

34. Do you have or have you ever had head injury?

When?

35. Do you have or have you ever had cancer?

When?

36. Do you have or have you ever had arthritis or rheumatism?

When?

37. Do you or have you ever had a hernia?

When?

38. Do you have or have you ever had carpal tunnel syndrome?

When?

39. Have you ever had any injury, operation or any disability not coveted by the above questions?

When?

40. Is there any question you do not understand?

Which questions?

All Statements and information provided are true to the best of my knowledge and relief. Misrepresentations, as to preexisting physical or mental conditions, may void your workers' compensation benefits.

All Statements and information provided are true to the best of my knowledge and relief. Misrepresentations, as to preexisting physical or mental conditions, may void your workers' compensation benefits.

Name of Applicant

Name of Applicant (Signed)

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Contact Information

1901 East Ave Panama City, FL 32405

8840 Fowler Ave Pensacola, FL 32534

4454 Entrepot Blvd Tallahassee, FL 32310

4826 Airport Rd Zephyrhills, FL 32542

Business Hours

Mon - Fri: 8:00 am - 5:00 pm
Sat - Sun: Closed

All Locations

LIST MAP

1901 East Ave Panama City, FL 32405 1901 N East Ave, Panama City, FL, 32405, United States
8840 Fowler Ave Pensacola, FL 32534 8840 Fowler Ave, Pensacola, FL, 32534, United States
4454 Entrepot Blvd Tallahassee, FL 32310 4454 Entrepot Blvd, Tallahassee, FL, 32310, United States
4826 Airport Rd Zephyrhills, FL 32542 4826 Airport Rd, Zephyrhills, FL, United States

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