Employment Application — Arizona Highway Safety Specialists

Application for Employment

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including age, sex, color, race, creed, national origin, religious persuasion, marital status, political belief, or disability that does not prohibit performance of essential job functions.

Federal law prohibits the employment of unauthorized aliens. All persons hired must submit satisfactory proof of employment authorization and identity (valid driver's license, birth certificate, passport, permanent resident alien ID card, etc.) prior to being hired.

Personal Information

Please Print

Date*

Last Name*First Name*Middle Name

Physical Address*

City*State*ZIP Code*

Mailing Address (if different than above)

E-mail Address*Telephone NumberCell Phone Number*

Emergency Contact*Relationship*Phone Number*

Position Applied For*Is there any information we would need about your name or use of another name for us to be able to check your work? Please specify.1. How were you referred to Arizona Highway Safety Specialists, Inc.?

2. Have you been convicted of a felony?*

Yes No

If yes, please explain:

Educational History

School	Name & Location	Years Completed	Degree/Diploma
Elem./Jr. High
High School
College
Tech Training
Other

Employment Record (last 5 years)

We will contact all employers listed unless you specifically exclude them below.

1. Employer

Company Name (Current/Most Recent Employer)

PositionFromTo

Address

Telephone #Manager/Supervisor

WageReason for Leaving

2. Employer

Company Name (Current/Most Recent Employer)

PositionFromTo

Address

Telephone #Manager/Supervisor

WageReason for Leaving

3. Employer

Company Name (Current/Most Recent Employer)

PositionFromTo

Address

Telephone #Manager/Supervisor

WageReason for Leaving

Employer to exclude from contactReason for exclusion

References (not relatives or former employers)

Reference 1 NameReference 1 PhoneReference 2 NameReference 2 Phone

Salary / Hourly Rate Requirements

If your application receives favorable consideration, what salary/hourly rate would you require?

$ Amount*Per (hour, year, etc.)*

Transportation

Your current driving record must be provided if driving company vehicles.

1. Do you have reliable transportation available to you at all times?*

Yes No

2. Do you have a valid driver's license?*

Yes No

3. Do you have a CDL?*

Yes No

License #Class

4. Have you had any traffic violations within the past three (3) years?*

Yes No

Explain:

Certification & Signature

Please read each statement carefully and check to confirm. Typing your full name below serves as your legal electronic signature under the federal ESIGN Act and Arizona's Uniform Electronic Transactions Act.

I hereby certify that the information provided herein is true and correct. I authorize you to make such investigations and inquiries of my personal, employment, and other related matters as may be necessary in arriving at an employment decision.I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application. I understand that false or misleading information may result in discharge.Should I be hired, I will read the Arizona Highway Safety Specialists, Inc. Policies and Procedures Manual provided to me, and abide by all conditions set forth therein. Failure to adhere to this agreement will be grounds for immediate termination. I further understand my employment is subject to maintaining an acceptable driving record for liability and auto insurance coverage by AHSS Underwriters.

Signature (type full legal name)*Date*

Your information will be sent securely to AHSS HR.

Arizona Highway Safety Specialists

Application for Employment

Personal Information

Educational History

Employment Record (last 5 years)

References (not relatives or former employers)

Work Availability

Salary / Hourly Rate Requirements

Transportation

Invitation to Self-Identification (Voluntary)

Certification & Signature