Medical Human Resources

Application For Employment

Last Name First Name Middle Name

Address City Stat Zip Code

e

Telephone No. Social Security No. Today's Date

Alt. Phone No. E-Mail Address

Education

High School Undergraduate Graduate

School Name &

Location

Years Completed 1 2 3 4 1 2 3 4 1 2 3 4

Diploma/Degree

Describe Course of

Study

Describe any honors

you

have received.

Describe any

specialized

training,

apprenticeships,

skills, extra

curricular

activities, or

seminars.

State any additional

information you feel

may be helpful to us

in considering your

application.

References

List three references who are not related to you and are not previous

employers.

Name Address Telephone

1.

2.

3.

What position are you Salary

applying for? Expected?

How did you hear about

this position?

WE ARE AN EQUAL OPPORTUNITY EMPLOYER

Application For Employment

Employment Experience

Start with your present or last job. Include any job-related military

service assignments and volunteer activities. You may exclude organizations

which indicate race, color, religion, gender, national origin, disability

or other protected status.

Employer Address Telephone

Number

Dates Job Title Supervisor Salary

Employed

Description of Work Reason For Leaving

Employer Address Telephone

Number

Dates Job Title Supervisor Salary

Employed

Description of Work Reason For Leaving

Employer Address Telephone

Number

Dates Job Title Supervisor Salary

Employed

Description of Work Reason For Leaving

Employer Address Telephone

Number

Dates Job Title Supervisor Salary

Employed

Description of Work Reason For Leaving

If you need additional space, please continue on a separate sheet of paper.

Special Skills and Qualifications

Summarize special job-related skills and qualifications acquired from

employment or other experience.

Please circle those that apply.

. Welding . Personal Computer Word Processing

(specify type) Application(s)

. wpm

Typing

. Ten Key by . Personal Computer Spreadsheet

Touch Application(s)

. Other Personal Computer

Applications

Application For Employment

Have you ever had any job-related training in the United States military?

Yes No If yes, describe:

Indicate any foreign languages you can speak, read, and/or write

List professional, trade, business or civic activities and offices held.

You may exclude memberships which would reveal sex, race, religion,

national origin, age, ancestry, disability or other protected status.

Have you ever filed an application with us before?

Yes No

Are you currently employed? Yes No

May we contact your present employer? Yes

No

If hired, can you verify employment eligibility to work in the U.S.?

Yes No

All offers will be contingent upon the verification of lawful employment

status as required by the Immigration Reform and Control Act of 1986.

On what date would you be available for work?

Have you been convicted of a crime? Yes

No

Conviction will not necessarily disqualify an applicant from employment.

If Yes, please explain

If applying for a position which requires driving:

Do you have a valid driver's license? Yes

No

If yes, what State Driver's License Number

Do you have a valid Commercial Driver's License (CDL)? Yes No

If yes, what State Driver's License Number

Applicant's Statement

I hereby certify that all information given by me in this application form

is true to the best of my knowledge and belief. I do hereby authorize the

investigation of any and all statements contained in said from liability

all persons or entities supplying or collecting such information. I

understand that any false statements or misrepresentations of facts in this

application will constitute sufficient cause for my dismissal. I am willing

to take a physical examination when required. If employed, I will abide by

all present and future Company rules and regulations.

Date Signature

For Company Use Only

Interviewed by Date Remarks

Date Hired New Employee's Title

Rate Per Hour Bi-Weekly Rate

Commissions Yes No

Estimated Annual Commissions Payroll Coding

Driver's License # State Expiration Date

Approved By:

Approved By:

Drug and Alcohol Screening Authorization

This form must be signed by the candidate/employee and one witness prior to

the test. The completed form will be retained by the medical facility

conducting the test.

I understand that as a condition of employment, I must satisfactorily

complete the Company's job-related medical inquiries, INCLUDING a urine

screening test to determine the presence of certain drugs and/or a Blood

Alcohol Test to determine the presence of alcohol.

As a candidate for Company employment, I understand that the presence

of one or more

of such drugs will disqualify me from further consideration for

employment.

Or

As a current Company employee, I understand that the presence of one

or more of such drugs may be cause for termination of my employment.

I hereby authorize the Company to conduct through its designated medical

examiner(s) a drug screen test, and I will hold Cummins Southern Plains,

LLC, its directors, employees and agents harmless from any claims arising

out of the information obtained through the medical inquiries or drug

screen test.

I, the undersigned, understand that the results will be released to the

Manager of Human Resources and will remain in my confidential medical file.

Signature of Applicant

(Print or Type Name)

Date

VOLUNTARY APPLICANT

AFFIRMATIVE ACTION

SURVEY

Position Applied For:

To help Cummins Southern Plains, Ltd. comply with various government

requirements, please mark the appropriate identification categories below.

Providing this information is voluntary and your application will not be

adversely affected if you respond or decline to respond. This information

will be used only in accordance with federal laws and regulations.

Information concerning any handicap or disability will be kept confidential

except as necessary for purposes of job assignment, accommodation, first

aid, and safety.

Race/Ethnicity (Please check all that apply.)

American Indian or Native Alaskan- A person having origins in

any of the original peoples of North America and South America

(including Central America) and who maintains a tribal affiliation or

community attachment.

Asian- A person having origins in the original peoples of the

Far East, Southeast Asia, or the Indian Subcontinent including for

example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the

Philippine Islands, Thailand, and Vietnam.

Black or African American- A person having origins in any of

the Black racial groups of Africa. Terms such as "Haitian" or "Negro"

apply in addition to "Black or African American".

Native Hawaiian or Other Pacific Islander- A person having

origins in any of the original peoples of Hawaii, Guam, Samoa, or other

Pacific Islands.

White- A person having origins in any of the original peoples

of Europe, North Africa, or the Middle East.

Hispanic or Latino - A person of Mexican, Puerto Rican, Cuban,

Central or South American, or other Spanish culture or origin

regardless of race.

Two or More Races- All persons who identify with more than one

of the above five races.

Gender

Male

Female

Contact this candidate