Job Application Name* First Last Phone*Email* Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Can you provide your Social Security Number if needed?YesNoOnly U.S. citizens or aliens who have a legal right to work in the U.S. are eligible for employment. Can you, upon employment, submit documentation verifying your legal right to work and your identity?YesNoHave you ever committed, been convicted of, plead guilty or not contest to, or had adjudication withheld with respect to a crime other than a minor traffic offense?YesNoIf yes, give dates and explain. List all such actions.Are you over the age of 18?YesNoHave you had any tickets within the last 5 years?YesNoAre you a veteran of the U.S. Military Service?YesNoIf yes, what branch?Beginning date of active dutyEnd date of active dutyRank at time of dischargeDrivers License #State of IssuanceHas your license ever been suspended or revoked?YesNoIf yes, explainDo you have any DUI or DWI convictions?YesNoIf yes, explainDo you have automobile insurance?YesNoDo you have reliable transportation to get to and from the job site(s)?YesNoHave you taken any illegal drugs in the past 30 days?YesNoAre you now employed?YesNoMay we contact your current employer?YesNoAre you on a layoff?YesNoAre you subject to recall?YesNoWill you work overtime if asked?YesNoAre there any hours, shifts or days you will not work?YesNoIf yes, explainDo you have any friends or relatives who work here?YesNoIf yes, please give name and relationship.Have you applied here before?YesNoIf yes, when?Have you ever been employed here before?YesNoIf yes, when?How did you hear about this job opening?What prompted you to apply?Educational HistoryHigh School InformationHigh School NameCity / StateYears CompletedDescribe specialized training, apprenticeship, skills and extracurricular activitiesCollege InformationCollege or OtherDiplomas or DegreesCity / StateYears CompletedCourse of StudyHonors ReceivedHave you ever had prior job or educational experience which relates to the job for which you are applying?YesNoIf Yes, ExplainFormer JobsList most recent first. Account for all time periods including unemployment, self employment and military service.1st Former EmployerEmployer 1Start DateEnd DateWork PerformedAddressPhoneJob TitleHourly Rate or Salary for Starting and FinalImmediate SupervisorMay we contact this employer?YesNoReason for leaving:2nd Former EmployerEmployer 2Start DateEnd DateWork PerformedAddressPhoneJob TitleHourly Rate or Salary for Starting and FinalImmediate SupervisorMay we contact this employer?YesNoReason for leaving:Please explain any gaps in employment history:Have you ever been asked to or been forced to resign?YesNoIf Yes, Explain.Did you receive any discipline in the last 12 months of active employment?YesNoIf Yes, ExplainWere you given a performance evaluation within the last 12 months of active employment?YesNoIf yes, what was the range of scores used and what was your score?Have you ever signed any non-compete agreement with any other employer that would restrict you from working for this company?YesNoIf yes, explain.Character ReferencesList 3 persons not related to you, whom you have known for at least 1 year.Name of Reference 1Phone # of Reference 1Address of Reference 1Occupation of Reference 1Name of Reference 2Phone # of Reference 2Address of Reference 2Occupation of Reference 2Name of Reference 3Phone # of Reference 3Address of Reference 3Occupation of Reference 3Position InformationJob Applying for:Salary RequestedWhen can you start?List any information/remarks you wish to have considered as a part of your application.Verify your InformationPlease Initial Here:I certify that the answers given by me to the above questions and statements are true and correct and hereby authorize you to contact references, past or present employers, persons, schools, law enforcement agencies and any other sources of information which may be relevant to my application for employment. It is understood and agreed that any misrepresentation, false statement or omissions by me in the application will be sufficient reason for rejection of my application or for dismissal at any time during my employment, without liability to this company.Please Initial Here:I further understand that no representation of the company has the authority to enter into any agreement for employment for any special period of time and that this company is not guarantying employment for anyone. No employment contract is created by virtue of my being hired by the company. I agree, as condition of employment, to sign an arbitration agreement governing the terms and conditions of my employment. I understand that the arbitration agreement is available to me immediately so that I may have ample time to review and understand its terms.Please Initial Here:If you are applying to be a sprinkler apprentice please read this agreement. If you are hired you will be required to take part in the ABC apprentice program. Classes are held 2 nights a week for 3 hours at the HCC campus in Tampa. Classes begin in August of each year and follow the HCC community college calendar. We ask that all apprentices sign the following apprentice agreement.Please Initial Here:I have read and reviewed all of the attached job descriptions. I understand that if I am hired for any of these positions that I must be able to meet the requirements listed in order to perform my job. Failure to be able to meet the physical requirements of this job may result in forfeiture of employment.Please Initial Here:If employed, I agree to abide by all the work and safety rules of Piper Fire Protection. I understand that this company is committed to maintaining a drug free workplace. I am aware that the company may require a drug test as part of the hiring process. Also, if employed, I fully realize that the company may conduct annual random drug testing of its employees.Digital Signature:I understand that this application will remain on file for 30 days consideration. After 30 days, if I am still interested in a position with this company, it will be necessary for me to complete a new application form.DateApplicant Signature:Date:If the application has gone through, you will be taken to our thank you page. If you do not get that page, please contact the HR department at 727-581-9339.