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Employee Data Sheet

Last Name:
First Name:
Middle Initial:
Date:
Street Address:
City:
State:
ZIP Code:
Telephone No:
Email:
Date of Birth:
Social Security Number:
DLD/ID Number:
State Issued:

Emergency Contacts

Full Name:
Relationship:
Address:
Phone:

Physician

Name:
Phone:
Address:

Education

Highest Level of Schooling Achieved & Location:

Position Information

Position Applying For:
Date Available to Start:
Rate of Pay Expected:
Years of CT Experience:
Are you legally allowed to work in the United States?YESNO
Special Skills, Qualifications or Knowledge- List any special skills, qualifications or knowledge you
possess:
Answering “yes” to the following question does not bar you from employment with OBR Cooling Towers. Have you plead “guilty” or “no contest” or been convicted of a crime in the past (7) years?YESNO
If yes, please explain
Can you pass a drug and alcohol test? Urinalysis?YESNO
Hair follicle?YESNO

Employment History

Employer:
Dates Employed:
To:
Supervisor Name & Phone No:
Job Title:
Hourly Wages:
Reason for Leaving?

Employer:
Dates Employed:
To:
Supervisor Name & Phone No:
Job Title:
Hourly Wages:
Reason for Leaving?

Verification Statement

I certify that all of the information in this application is true and correct. I understand that misrepresentation or
falsifying information can result in not being considered for employment. My rate of pay and benefits have been
explained to me. I understand and agree to these terms
Employee Signature:
Date: