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General Information

• First Name*
• Last Name*
• Address*
• Previous Address if less than 5 years at the current address (City, State)
• City*
• State* Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
• Zip Code*
• Email Address*
• Home Phone*
• Alternate Phone Number

• If hired, can you provide verification of your legal right to work in the United States?*

  Yes
  No
  

• Are you at least 18 years of age?*

  Yes
  No
  

• Have you been terminated or asked to resign? If yes, provide details.*

  Yes
  No
  

• Conviction record may not necessarily prohibit employment. Factors such as date, nature and offense will be considered.

• Have you pled guilty or "no contest" to a crime, been convicted of a crime, had adjudication withheld or prosecution deferred? If yes, please give date and details.*

  Yes
  No
  

• Have you been a defendant in a suit such as assault, battery, false imprisonment, wrongful death? If yes, please give date and details.*

  Yes
  No
  

Position

• Position Applying For:*
• Minimum pay rate $:*
• Date available to start:*

• How did you learn about our company and/or position? If employee referral, provide name:

• Are there days or hours you would be unable to work?*

  Yes
  No
  

• If yes, when?

• Will you be able to work overtime?*

  Yes
  No
  

• Will you be able to travel within Florida?*

  Yes
  No
  

• Have you applied with our company before?*

  Yes
  No
  
• If yes, when?

• Have you been employed by Modern Plumbing Industries?*

  Yes
  No
  
• If yes, when?
• Reason for Leaving?

Education

High School

• High School Name:*
• City/State:*

• Graduated:*

  Yes
  No
  

• GED:*

  Yes
  No
  

College

• College Name:
• City/State:
• Years complete: 0 1 2 3 4

Graduate School

• College Name:
• City/State:
• Years complete: 0 1 2 3 4

• Are you planning on Continuing Education?:

  Yes
  No
  
• If yes, when, where and what courses?

• List any educational honors and activities involved in during school:

• List and describe specialized training:

• Professional License:
• Certification:

Driving

Some positions require reporting to different job sites. Reliable transportation is necessary.

• Will you be able to report on a regular consistent basis?*

  Yes
  No
  
• If no, explain:

• Do you have a valid driver's license issued in Florida?*

  Yes
  No
  

• Any history of license restrictions?*

  Yes
  No
  

• If yes, explain:

Safety

• List Safety Training:

• Will you abide by our safety rules?*

  Yes
  No
  

• Have you been disciplined for violating safety rules?*

  Yes
  No
  

• If yes, explain:

Skills

• Word
• Excel
• Access
• Outlook

• List other programs:

• What skills qualify you for a position?

Professional / Industry References

List three references. Do not use relatives.

#1

• Name:*
• City:*
• Phone:*
• Occupation:*

#2

• Name:*
• City:*
• Phone:*
• Occupation:*

#3

• Name:*
• City:*
• Phone:*
• Occupation:*

Employment

Start with current or most recent employer

Employer #1

• Employer: *
• Position: *
• City, State: *
• Telephone: *
• Supervisor's Name: *

Salary

• Starting: *
• Ending: *

Dates

• Starting: * (mo/yr)
• Ending: * (mo/yr)

• Duties: *
• What did you like most about your job?
• What did you like least about your job?
• Reason for leaving: *

• Eligible for Re-hire? *

  Yes
  No
  

Employer #2

• Employer:
• Position:
• City, State:
• Telephone:
• Supervisor's Name:

Salary

• Starting:
• Ending:

Dates

• Starting: (mo/yr)
• Ending: (mo/yr)

• Duties:
• What did you like most about your job?
• What did you like least about your job?
• Reason for leaving:

• Eligible for Re-hire?

  Yes
  No
  

Employer #3

• Employer:
• Position:
• City, State:
• Telephone:
• Supervisor's Name:

Salary

• Starting:
• Ending:

Dates

• Starting: (mo/yr)
• Ending: (mo/yr)

• Duties:
• What did you like most about your job?
• What did you like least about your job?
• Reason for leaving:

• Eligible for Re-hire?

  Yes
  No
  

Supplemental Employment Information

If you worked using another name, please list name(s) here:

• Name:
• at (company):
• Name:
• at (company):

• Are you currently employed?*

  Yes
  No
  

• If yes, may we contact your present employer?*

  Yes
  No
  

• Have you been disciplined, warned, demoted, suspended, placed on probation or terminated?*

  Yes
  No
  

• If yes, explain:

Applicant's Statement

I understand that if my application is considered for employment, I authorize a verification of all statements and information. In connection with my application, I understand that results of the background inquiries and personal information may be released to Modern Plumbing Industries. I also release any and all persons, companies, or agencies responding to such investigation from any liability for damage due to releasing information.

I certify that answers given are true and complete to the best of my knowledge. I further understand that misrepresentation of facts on this application or interview is cause for rejection of this application or for subsequent dismissal from employment no matter when discovered.

In consideration of employment, I agree to comply with the rules and regulations of Modern Plumbing Industries and my employment can be terminated for any reason and without notice, at any time, at the option of either the Company or myself. I further understand that no oral promise, policy, business practice or other procedure, including any handbooks or manuals, constitutes an employment contract or modification of the at-will employment relationship between myself and Modern Plumbing Industries.

I understand that no supervisor or other official of Modern Plumbing Industries (except its President) has the authority to enter into an agreement with me or to make any agreement contrary to foregoing.

Applications (via internet, email, fax, mail, or submitted in person) remain active for sixty (60) days.

I understand MPI reserves the right to request pre-employment, post accident, random or reasonable suspicion drug screening.

DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE APPLICANT'S STATEMENT.

• Digital Signature:*
• Date:*

By typing your name in the signature box above, you are signing this document and stating that you read and understand the Applicant's Statement.

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