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First Name

Middle Name

Last Name

Date of Birth

Email

Phone

Street Address

City, State, Zip Code

How long have you lived at this address?

Highest Level of Education

Name of Last School Attended

City & State of Last School Attended

Select Desired Position

Select Desired Location

Desired Salary/Wage

Date Available to Start Work

Have you worked for TD&I before?

Yes

No

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Is there any reason you may not be able to perform the functions of the job for which you are applying?

How did you hear about us?

If one of our current employees referred you, please list their name.

Are you currently employed?

Yes

No

Previous Employer Name

Previous Position/Title

Previous Employer Address

Previous Supervisor's Name

Previous Employer Phone

Dates Employed at Previous Job

Reason for Leaving

Were you subject to the FMCSR (Federal Motor Carrier Safety Regulations) while previously employed?

Yes

No

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If you answered "no" to this question, then the following question will not be "yes."

Was your previous job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirement of 49 CFR Part 40?

Yes

No

Driver's License Number

Driver's License Class

Issuing State

Do you have any traffic convictions or forfeitures in the last 3 years? (Do not include parking violations)

Yes

No

If you have any traffic convictions or forfeitures, please indicate the date and charge(s)

Have you ever been denied a license, permit, or privilege to operate a motor vehicle?

Yes

No

Has any license, permit, or privilege ever been suspended or revoked?

Yes

No

Affirmative Action Questionnaire

The federal government under Executive Order 11246 requires the company to report sex and race/ethnic origin of applicants for employment. Applicants are considered for all positions without regard to race, color, creed, religion, gender, national origin, age, ancestry, arrest/conviction record, presence of a non-job related medical condition or disability, marital or veteran status, sexual orientation, status with regard to public assistance, or any other legally protected status. The information requested below is voluntary; failure to provide it will not jeopardize or adversely affect consideration of your employment. Your cooperation is appreciated. The information obtained will be kept confidential and may only be used in accordance with applicable laws. When data is reported, it will not identify any specific individual.

Gender

Male

Female

Prefer Not to Answer

Ethnic Group Identification - Are you Hispanic or Latino?

Yes

No

Prefer Not to Answer

If you answered "No," please select a race from the options below.

Answered "Yes" Above

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Two or More Races

Prefer Not to Answer

I hereby certify that this application was completed by me and that all information in it is true and complete to the best of my knowledge.

I Agree

In the event of a job offer from TD&I Cable Maintenance, Inc., I hereby authorize them to access my driving records and all other applicable motor vehicle history for the purposes of investigation as required by Sections 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations as a prerequisite to employment.

I Agree

I Disagree

In the event of a job offer from TD&I Cable Maintenance, Inc., I hereby consent to a drug test and physical as a prerequisite to employment.

I Agree

I Disagree

In the event of a job offer from TD&I Cable Maintenance, Inc., I hereby authorize them to request a background check from a consumer reporting agency as a prerequisite to employment.

I Agree

I Disagree

I understand that, as part of the employment process, TD&I Cable Maintenance, Inc. may obtain information about me, where permitted, which may pertain to my employment records, driving history records, criminal history, civil records, alcohol and drug testing, verification of my academic and/or professional credentials, and information and/or copies of documents from any military service records. I understand and acknowledge that the information provided in any consumer reports or investigative consumer reports may assist my prospective employer in making a determination regarding my suitability as an employee, even after a job offer has been extended. Additionally, I understand that due to certain customer contractual requirements, TD&I Cable Maintenance, Inc. is bound to ensure their customer background check criteria are met by all prospective and current employees. I further understand that, under the FCRA, in the event of Adverse Action, I may request a copy of any consumer report used to determine my suitability as an employee.

I Acknowledge

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TD&I Cable Maintenance, Inc. is committed to providing equal employment opportunities to all individuals. All considerations with regards to the details from an applicant’s background check and other personal information provided will be considered without discrimination to race, color, creed, religion, gender, national origin, age, ancestry, arrest/conviction record, presence of a non-job related medical condition or disability, marital or veteran status, sexual orientation, status with regard to public assistance, or any other legally protected status.

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TD&I Cable Maintenance, Inc. Employment Application

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