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? Yes No Only 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? Yes No Have 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? Yes No If yes, give dates and explain. List all such actions.Are you over the age of 18? Yes No Have you had any tickets within the last 5 years? Yes No Are you a veteran of the U.S. Military Service? Yes No If yes, what branch? Beginning date of active duty End date of active duty Rank at time of discharge Drivers License # State of Issuance Has your license ever been suspended or revoked? Yes No If yes, explainDo you have any DUI or DWI convictions? Yes No If yes, explain Do you have automobile insurance? Yes No Do you have reliable transportation to get to and from the job site(s)? Yes No Have you taken any illegal drugs in the past 30 days? Yes No Are you now employed? Yes No May we contact your current employer? Yes No Are you on a layoff? Yes No Are you subject to recall? Yes No Will you work overtime if asked? Yes No Are there any hours, shifts or days you will not work? Yes No If yes, explainDo you have any friends or relatives who work here? Yes No If yes, please give name and relationship.Have you applied here before? Yes No If yes, when?Have you ever been employed here before? Yes No If yes, when?How did you hear about this job opening?What prompted you to apply?Educational HistoryHigh School InformationHigh School Name City / State Years Completed Describe specialized training, apprenticeship, skills and extracurricular activitiesCollege InformationCollege or Other Diplomas or Degrees City / State Years Completed Course of StudyHonors ReceivedHave you ever had prior job or educational experience which relates to the job for which you are applying? Yes No If Yes, ExplainFormer JobsList most recent first. Account for all time periods including unemployment, self employment and military service.1st Former EmployerEmployer 1 Start Date End Date Work Performed Address Phone Job Title Hourly Rate or Salary for Starting and Final Immediate Supervisor May we contact this employer? Yes No Reason for leaving:2nd Former EmployerEmployer 2 Start Date End Date Work Performed Address Phone Job Title Hourly Rate or Salary for Starting and Final Immediate Supervisor May we contact this employer? Yes No Reason for leaving:Please explain any gaps in employment history:Have you ever been asked to or been forced to resign? Yes No If Yes, Explain.Did you receive any discipline in the last 12 months of active employment? Yes No If Yes, ExplainWere you given a performance evaluation within the last 12 months of active employment? Yes No If 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? Yes No If yes, explain.Character ReferencesList 3 persons not related to you, whom you have known for at least 1 year.Name of Reference 1 Phone # of Reference 1 Address of Reference 1 Occupation of Reference 1 Name of Reference 2 Phone # of Reference 2 Address of Reference 2 Occupation of Reference 2 Name of Reference 3 Phone # of Reference 3 Address of Reference 3 Occupation of Reference 3 Position InformationJob Applying for: Salary Requested When 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.Date Applicant 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.