Application for Employment

PRE-EMPLOYMENT QUESTIONNAIRE EQUAL OPPORTUNITY EMPLOYER

Personal Information Date

NAME (LAST NAME FIRST)		SOCIAL SECURITY NUMBER
PRESENT ADDRESS	CITY	STATE	ZIPCODE
PERMANENT ADDRESS	CITY	STATE	ZIPCODE
HOME PHONE NO.	CELL PHONE NO.	REFERRED BY

Employment Desired

POSITION

DATE YOU CAN START

SALARY DESIRED

ARE YOU EMPLOYED NOW?

YES

IF SO, MAY WE INQUIRE OF YOUR PRESENT EMPLOYER?

YES NO

EVER APPLIED TO THIS COMPANY BEFORE?

YES NO

WHERE

WHEN

EDUCATION HISTORY

	NAME & LOCATION OF SCHOOL	YEARS ATTENDED	DID YOU GRADUATE	SUBJECTS STUDIED
HIGH SCHOOL
COLLEGE
TRADE, BUSINESS, OR CORRESPONDENCE SCHOOL

GENERAL INFORMATION

SPECIAL TRAINING
SPECIAL SKILLS
US MILITARY OR NAVAL SERVICE	RANK
HAVE YOU EVER BEEN CONVICTED OF, PLEAD GUILTY/NO CONTEST TO A CRIME? IF YES, PLEASE EXPLAIN.

FORMER EMPLOYERS (LIST BELOW LAST FOUR EMPLOYERS, MOST RECENT FIRST)

DATE, MONTH, & YR	NAME & ADDRESS OF EMPLOYER	POSITION / SALARY	REASON FOR LEAVING
FROM
TO
FROM
TO
FROM
TO
FROM
TO

REFERENCES

(GIVE BELOW THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR.

NAME	PHONE	BUSINESS/PROFESSION	YEARS KNOWN

AUTHORIZATION

"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.:

DATE SIGNATURE INTERVIEWED BY

Job Requirements for Electricians and Helpers:

Description of electrical work:

Plans layout, installs and repairs wiring, electrical fixtures, apparatus, and control equipment. Plans new or modified installations to minimize waste of materials, provide access for future maintenance, and avoid unsightly, hazardous, and unreliable wiring, consistent with specifications and local electrical codes. Prepares sketches showing location of wiring and equipment, or follows diagrams, blueprints, and specifications, ensuring that concealed wiring is installed before completion of future walls, ceilings, and floorings. Measures, cuts, bends, threads, assembles, and installs electrical conduit, using tools, such as hacksaw, pipe threader, and conduit bender. Pulls wiring through conduit assisted by electrical helper. Splices wires by stripping insulation from terminal leads, using knife or pliers, twisting or soldering wires together, and applying tape or terminal caps. Connect wiring to lighting fixtures and power equipment, using hand tools. Installs control and distribution apparatus, such as switches, relays, and circuit-breaker panels, fastening in place with screws or bolts, using hand tools and power tools. Connects power cables to equipment, such as electric motors, and installs grounding leads. Tests continuity of circuit to ensure electrical compatibility and safety of components, using testing instruments, such as ohmmeter, battery buzzer, and oscilloscope. Observes functioning of installed equipment or system to detect hazards and need for adjustments, relocation, or replacement. May repair faulty equipment or systems and may cut and weld steel structural members, using flame-cutting and welding equipment. May be designated according to work location as mine electrician (Mine or Quarry). May be required to hold electrical license.

Demands of electrical work:

Ratings:

Occasionally (Activity or condition exists up to 1/3 of the time) Frequently (Activity or condition exists 1/3 to 2/3 of the time) Constantly (Activity or condition exists 2/3 or more of the time)

Heavy Work (Exerting 50 to 100 lbs. of force occasionally, or 25 to 50 lbs. of force frequently, or 10 to 20 lbs. of force constantly to move objects)

Activity Rating Description

Climbing	Occasionally	Ascending or descending ladders, stairs, scaffolding, ramps, poles, and the like, using feet and legs or hands and arms.
Balancing	Occasionally	Maintaining body equilibrium to prevent falling when walking, standing, crouching, or running on narrow, slippery, or erratically moving surfaces.
Stooping	Occasionally	Bending body downward and forward by bending spine at the waist, requiring full use of the lower extremities and back muscles.
Kneeling	Occasionally	Bending legs at knees to come to rest on knee or knees.
Crouching	Occasionally	Bending body downward and forward by bending legs and spine.
Crawling	Occasionally	Moving about on hands and knees or hands and feet.
Reaching	Frequently	Extending hand(s) and arm(s) in any direction.
Handling	Frequently	Seizing, holding, grasping, turning, or otherwise working with hands. Fingers are involved only to the extent that they are an extension of the hand, such as to turn a switch or shift automobile gears.
Finger Dexterity	Occasionally	The ability to make precisely coordinated movements of the fingers of one or both hands to grasp, manipulate, or assemble very small objects.
Talking	Occasionally	Expressing or exchanging ideas by means of the spoken word to impart oral information to clients or to the public and to convey detailed spoken instructions to other workers accurately, loudly, or quickly.
Hearing	Occasionally	Perceiving the nature of sounds by ear.
Oral Comprehension	Frequently	The ability to listen to and understand information and ideas presented through spoken words and sentences.

Condition Rating Description

Near Acuity	Frequently	Clarity of vision at 20 inches or less.
Far Acuity	Frequently	Clarity of vision at 20 feet or more.
Depth Perception	Occasionally	Three-dimensional vision. Ability to judge distances and partial relationships so as to see objects where and as they actually are.
Visual Accommodation	Frequently	Adjustment of lens of eye to bring an object into sharp focus. This factor is required when doing near point work at varying distances from the eye.
Color Vision	Frequently	Ability to identify and distinguish colors.
Strength	Heavy Work	An overall rating that reflects the following activities: Lifting — raising or lowering an object from one level to another (includes upward pulling). Carrying transporting an object, usually holding it in the hands or arms or on the shoulder. Pushing — exerting force upon an object that the object moves away from the force (includes, striking, kicking, and treadle actions). Pulling — exerting force upon an object so that the object moves toward the force (includes jerking). Controlling — using one or both arms or hands or one or both feet or legs to move controls on machinery or equipment. Controls include but are not limited to buttons, knobs, pedals, levers, and cranks. Standing — remaining on one's feet in an upright position at a workstation without moving about. Walking — Moving about on foot.
Problem Sensitivity	Occasionally	The ability to tell when something is wrong or is likely to go wrong. It does not involve solving the problem, only recognizing there is a problem.
Trunk Strength	Constantly	The ability to use your abdominal and lower back muscles to support part of the body repeatedly or continuously over time without 'giving out' or fatiguing.

Environmental conditions of electrical work:

Condition Rating Description

Exposure to Weather	Frequently	Exposure to outside atmospheric conditions.
Extreme Cold	Occasionally	Exposure to non weather — related cold temperatures.
Extreme Heat	Occasionally	Exposure to non weather — related hot temperatures.
Wet and/or Humid	Occasionally	Contact with water or other liquids or exposure to non-weather related humid conditions.
Vibration	Occasionally	Exposure to a shaking object or surface.
Proximity to moving mechanical parts	Occasionally	Exposure to possible bodily injury from moving mechanical parts of equipment, took or machinery.
Electrical Shock	Frequently	Exposure to possible bodily injury from electrical shock.
Working in high, exposed places	Frequently	Exposure to possible bodily injury from falling.
Toxic/Caustic Chemicals	Occasionally	Exposure to possible bodily injury from toxic or caustic chemicals.
Noise intensity levels	Frequently	Exposure to potential hearing damage due to high noise levels.
Exposure to dust and Fumes	Occasionally	Exposure to conditions such as fumes, noxious odors, dusts, mists, gases, and poor - ventilation that affect the respiratory system, eyes, or the skin.

Do you require accommodation to perform the tasks/activities in the conditions detailed above? Yes No If yes, please detail the accommodation needed:

Signature: ________________________________________________________________________________

WORK EXPERIENCE

TRUMBO ELECTRIC INC. APPLICATION FOR EMPLOYMENT PART II

Please circle the number that best represents your knowledge and skill in the following areas. One

(1) means that you have very little understanding and exposure to the given area. Five (5) means that you have a highly advanced understanding and skill level in the given area. Three (3) means that you have a moderate knowledge of the given area. If you have no exposure at all to the given area please leave it blank.

OSHA REGULATIONS	1	2	3	4	5
WORK LAYOUT	1	2	3	4	5
CUSTOMER RELATIONS	1	2	3	4	5
NEC KNOWLEDGE	1	2	3	4	5
TOOL AND MATERIALS	1	2	3	4	5
ELECTRICAL THEORY	1	2	3	4	5
CONDUIT INSTALLATION	1	2	3	4	5
WIRE PULLING OPERATIONS	1	2	3	4	5
WIREWAYS AND BUSDUCTS	1	2	3	4	5
FIXTURE INSTALLATION	1	2	3	4	5
SWITCHES	1	2	3	4	5
CIRCUITS	1	2	3	4	5
SPECIAL SENSORS	1	2	3	4	5
DISCREAT WIRING (PLCs)	1	2	3	4	5
METER USAGE AND TESTING	1	2	3	4	5
BLUE PRINT READING	1	2	3	4	5
MOTORS	1	2	3	4	5
PUMPS	1	2	3	4	5
GROUNDING KNOWLEDGE	1	2	3	4	5
STARTERS	1	2	3	4	5
TRANSFORMERS	1	2	3	4	5
SWITCHGEAR	1	2	3	4	5
SERVICE ENTRANCE	1	2	3	4	5
GENERATORS	1	2	3	4	5
AUTOMATIC TRANSFER SWITCHES	1	2	3	4	5
DATA AND NETWORK	1	2	3	4	5
FIRE ALARM SYSTEMS	1	2	3	4	5
EMERGENCY LIGHTS/POWER	1	2	3	4	5
SECURITY SYSTEMS	1	2	3	4	5
HIGH VOLTAGE	1	2	3	4	5
HOSPITAL CODES	1	2	3	4	5
CLASSIFIED LOCATIONS IONS	1	2	3	4	5
PROGRAM AUTOMATED EQUIPMENT	1	2	3	4	5
DIAGNOSTICS WITH COMPUTER	1	2	3	4	5
EQUIPMENT OPERATION	1	2	3	4	5

ESSAY

Instructions: Briefly answer the following questions in a paragraph or less.

Why are you seeking employment at Trumbo Electric?
What specifically do you know about our operation?

Additional Comments:

The facts set forth represent the truth to the best of my knowledge. I understand that if employed, false statements on this application shall be considered sufficient cause for dismissal.