Apply "*" indicates required fields Step 1 of 8 12% Personal DataName First Middle Last Social Security NumberAre you 18 years of age or older? Yes No Are you legally eligible for employment in this country? Yes No Please ExplainHome Phone:Cell/Alternate Phone:Email Address* Street Address City State Zip Code Previous name(s)/alias (ie. maiden name):Do you have a valid driver’s license? Yes No StateLicense No:Expiration Date: APPLICATION / EMPLOYMENT STATUSDate of application:* MM slash DD slash YYYY List any prior dates of employment and positions with R&S Maintenance Services:List position and/or type of work for which you are applying:If referred to this company for employment, who provided the recommendation?Type of employment desired: Full-Time Part-Time Seasonal Desired hourly wage:Date available for work:* MM slash DD slash YYYY Are you available to work overtime, if necessary? Yes No EDUCATION HISTORYType of School(Please Select)High SchoolCollegeGraduateTechnical, Trade or OtherName and Location of SchoolDid You Graduate? Yes No Years CompletedCourse of StudyAdd another school? Yes No Type of School(Please Select)High SchoolCollegeGraduateTechnical, Trade or OtherName and Location of SchoolDid You Graduate? Yes No Years CompletedCourse of StudyAdd another school? Yes No Type of School(Please Select)High SchoolCollegeGraduateTechnical, Trade or OtherName and Location of SchoolDid You Graduate? Yes No Years CompletedCourse of StudyAdd another school? Yes No Type of School(Please Select)High SchoolCollegeGraduateTechnical, Trade or OtherName and Location of SchoolDid You Graduate? Yes No Years CompletedCourse of Study Employment HistoryPlease list your current or most recent employer here:Start DateMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920End DateMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920EmployerPhoneImmediate SupervisorAddress Street Address City State Zip Code Starting Job Title:Ending Job TitleStarting Pay RateEnding Pay RateSummarize the nature of work performed and your job responsibilities:Reason for LeavingMay we contact this employer for reference? Yes No Later, not at this time Please ExplainPlease list your second most recent employer here:Start DateMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920End DateMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920EmployerPhoneImmediate SupervisorAddress Street Address City State Zip Code Starting Job Title:Ending Job TitleStarting Pay RateEnding Pay RateSummarize the nature of work performed and your job responsibilities:Reason for LeavingPlease list your third most recent employer here:Start DateMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920End DateMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920EmployerPhoneImmediate SupervisorAddress Street Address City State Zip Code Starting Job Title:Ending Job TitleStarting Pay RateEnding Pay RateSummarize the nature of work performed and your job responsibilities:Reason for LeavingMay we contact this employer for reference? Yes No Later, not at this time Please ExplainReason for LeavingMay we contact this employer for reference? Yes No Later, not at this time Please ExplainPERIODS OF UNEMPLOYMENTPlease provide dates and details of any periods of unemployment during the past 7 years (include gaps in employment greater than 30 days): MILITARY SERVICE RECORDHave you ever been in the military? Yes No BranchStart Date of serviceMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920End Date of serviceMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date of DischargeMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Training and special skillsCRIMINAL RECORDNote: A criminal record or conviction may not disqualify you from consideration for employment. However, you will not be considered if you fail to truthfully complete this section.Have you ever been convicted of a crime? Yes No Please list date and nature of offense(s):Name and location of court:Disposition of case:Name of probation/parole officer:Phone NumberMay we contact him//her? Yes No Are there any felony or misdemeanor charges pending against you? Yes No Please list date and nature of offense(s) PERSONAL REFERENCE DATAReference 1NameRelationshipAddress Street Address City State Zip Code PhoneEmail AddressReference 2NameRelationshipAddress Street Address City State Zip Code PhoneEmail AddressReference 3NameRelationshipAddress Street Address City State Zip Code PhoneEmail Address PHYSICAL CAPABILITIES / JOB DUTIESThe following functions may be essential requirements of this position. Please rate your ability to perform the following functions and tasks using a scale of 1 to 10 (1 = CANNOT PERFORM and 10 = CAN EASILY PERFORM):Lift up to 50 lbs. 16 to 20 times per day.Please Select12345678910Climb a 25-ft. ladder on occasion.Please Select12345678910Work in adverse conditions (e.g. dusty/windy weather, rain, summer heat, cold temperatures, etc.).Please Select12345678910Willing to perform duties not generally associated with your position (i.e. fill in where short staffed).Please Select12345678910Follow multiple instructions or orders simultaneously.Please Select12345678910Act in a professional manner while interacting with clients and other necessary contacts.Please Select12345678910Work well with others and resolve problems in a responsible manner.Please Select12345678910Maintain cleanliness/organization of work area and tools.Please Select12345678910Use power tools (please list specific tools below in the Equipment Experience section).Please Select12345678910Perform duties requiring occasional extension of your arms over your head.Please Select12345678910Bend and/or squat repeatedly throughout the day.Please Select12345678910Work as a team on a project or task and respect the chain-ofcommand.Please Select12345678910EQUIPMENT EXPERIENCEList skills & equipment experience relevant to the job for which you are applying (include tools you are qualified to operate): ABOUT HCI & THE HIRING PROCESS:Hatcher Consultants, Inc., or “HCI,” provides management-consulting services to R&S Maintenance Services, Inc. (hereinafter referred to as “Company” or “R&S”). HCI is not an employment placement agency and applicants offered employment become employees of R&S. The Company has hired HCI to assist in providing a safe and quality work environment. Please review your application to ensure that all questions have been answered to the best of your ability. Failure to completely fill out this Application for Employment may result in disqualification from consideration for employment. HCI will be screening applications for completeness, honesty, and accuracy. THIS SCREENING PROCESS MAY INCLUDE THE ACQUISITION OF AN “INVESTIGATIVE CONSUMER REPORT” INCLUDING ANY HISTORY OF CRIMINAL CONVICTIONS, JOB SAFETY, EMPLOYMENT HISTORY (INCLUDING ATTENDANCE AND/OR OTHER PERFORMANCE-RELATED ISSUES), AND OTHER INFORMATION DEEMED RELEVANT TO THE APPLICANT-SELECTION PROCESS. Attached to this application is a copy of the federal Fair Credit Reporting Act, as it pertains to application screening and background checks. Questions regarding your application, its status, or the current hiring needs of R&S, should be directed to HCI (Hours: M – F, 8:00 AM to 5:00 PM), Tel: 785-271-5557 or e-mail: Employment@hatcherconsultants.com.PLEASE READ THE FOLLOWING STATEMENT & SIGN/ACKNOWLEDGE:I HEREBY AUTHORIZE HATCHER CONSULTANTS, INC., AND AGENTS ACTING ON BEHALF OF HCI, TO REQUEST AND OBTAIN PERTINENT INFORMATION (DETAILED IN THE ABOVE PARAGRAPH) FROM MY FORMER EMPLOYERS. I RELEASE ALL FORMER EMPLOYERS PROVIDING SAID INFORMATION FROM ANY AND ALL LIABILITY THAT MAY ARISE BY THE TRUTHFUL DISCLOSURE OF THE AFOREMENTIONED EMPLOYMENT INFORMATION. I FURTHER AUTHORIZE HCI TO DISCLOSE MY EMPLOYMENT HISTORY AND DATA LISTED WITHIN THIS APPLICATION TO COMPANIES/ORGANIZATIONS WHICH HAVE A BUSINESS RELATIONSHIP WITH HCI. I UNDERSTAND THAT IT IS THE POLICY OF THE COMPANY THAT ALL APPLICANTS OFFERED EMPLOYMENT SUCCESSFULLY COMPLETE A DRUG AND/OR ALCOHOL SCREEN PROVIDING EVIDENCE OF THE ABSENCE OF ILLICIT AND/OR IMPAIRING SUBSTANCES. I ALSO UNDERSTAND THAT A CONFIRMED TEST RESULT FOR THE PRESENCE OF AN ILLICIT AND/OR IMPAIRING SUBSTANCE, OR MY FAILURE TO SUBMIT TO A DRUG SCREEN AS DIRECTED, WILL PRECLUDE ME FROM CONSIDERATION FOR EMPLOYMENT WITH THE COMPANY FOR A PERIOD OF ONE (1) YEAR. If 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. I understand that only an authorized Company officer or designee has the authority to make any assurances to the contrary. I also understand that if I am hired, I will be required to provide proof of identity and legal work authorization. The Company is an Equal Opportunity Employer and does not discriminate on the basis of race, color, national origin, gender, sexual preference, religion, age, or disability in employment or the provision of services. I certify that the information contained in this Application for Employment, including any resume or other attachment(s), is true, correct, and complete to the best of my knowledge. I understand that any false statements, misrepresentations, or omissions I have made on this application or any supplement thereto, will be sufficient grounds for rejection of this application by HCI, or discharge from employment if already hired. My signature acknowledges that I have read and agree to the above statements and affirmations.Signature*Date* MM slash DD slash YYYY
