APPLICATION FOR EMPLOYMENT

5711 Lacey Blvd SE, Suite 305 - POB 5355 Lacey Washington 98509 Tel: 360 628-8342 Fax: 877 655-9893 Email [email protected]

1

APPLICATION FOR EMPLOYMENT

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age, sex, religion, national origin, marital status, or the presence of non-job related medical condition or handicap.

Last Name First Middle Maiden Date of Application Street Address Home Telephone

City, State, Zip Code

Cell Phone Social Security Number

Email Address

Are you 18 years of age or older? Yes No Alternate Email Address

EMPLOYMENT DESIRED

Position Desired Date Available

Wage or Salary Desired

What range of hours are you willing to work weekly?

Are you willing to be on call? Yes No

Can you work nights? Yes No

Are you willing to work out of town?

Yes No

Hours Available From To Monday Tuesday Wednesday Thursday Friday Saturday Sunday Type of Employment Desired

Full Time Part Time Temporary Are you legally eligible for employment in this country? Yes No

Proof of U.S. citizenship or immigration status will be required upon employment.

Are you employed now? If so may we enquire of your present employer?

Employer Name:_____________________________

2

EDUCATION

Level Name and Location of

School Diploma or Degree (Credits Earned

if No Degree)

Overall

GPA Attendance Dates _From Majors/ Minors Mo/Yr Mo/Yr To High School Business, Trade, or Technical College Graduate School Other If degrees were received under a name other than that listed on this application, please provide your full name at the time the degree was awarded: Degree: Name At Time Earned:

Scholastic Achievements:

MILITARY HISTORY

Have you ever been in the armed forces? Yes No

Were you honorably discharged? Yes No

Are you now a member of the National Guard? Yes No

Specialty:

Date Entered:

Discharge Date:

SKILLS AND QUALIFICATIONS

Summarize specific skills and qualifications acquired from employment or other experiences that are related to the position for which you are applying (e.g., computer skills, software applications, and foreign languages):

3

EMPLOYMENT HISTORY

Please provide a COMPLETE employment history, even if a resume is submitted with this application. List ALL employers, assignments, or volunteer activities, starting with the most recent, including military employment. Explain any gaps in employment in the “Comments” section below. Please use the “Employment History Continuation Sheet” if additional space is needed.

(1) Present/Most Recent Employer Telephone

Dates Employed Summarize the nature of the work performed and job responsibilities. From Mo/Yr Mo/Yr To Address Job Title Hourly Rate/Salary Starting Immediate Supervisor and Title

$

per Type of Employment Full Time Part Time

Temporary Other

Hourly Rate/Salary Final Reason for leaving or why you are considering leaving?

$

per

(2) Next Previous Employer

Telephone

Dates Employed Summarize the nature of the work performed and job responsibilities. From Mo/Yr Mo/Yr To Address Job Title Hourly Rate/Salary Starting Immediate Supervisor and Title

$

per Type of Employment Full Time Part Time

Temporary Other Hourly Rate/Salary _Final Reason for leaving?

$

per

(3) Next Previous Employer

Telephone

Dates Employed Summarize the nature of the work performed and job responsibilities. From Mo/Yr Mo/Yr To Address Job Title Hourly Rate/Salary Starting Immediate Supervisor and Title

$

per Type of Employment Full Time Part Time

Temporary Other Hourly Rate/Salary _Final Reason for leaving?

$

per

4

(4) Next Previous Employer

Telephone

Dates Employed Summarize the nature of the work performed and job responsibilities. From Mo/Yr Mo/Yr To Address Job Title Hourly Rate/Salary Starting Immediate Supervisor and Title

$

per Type of Employment Full Time Part Time

Temporary Other Hourly Rate/Salary _Final Reason for leaving?

$

per

(5) Next Previous Employer

Telephone

Dates Employed Summarize the nature of the work performed and job responsibilities. From Mo/Yr Mo/Yr To Address Job Title Hourly Rate/Salary Starting Immediate Supervisor and Title

$

per Type of Employment Full Time Part Time

Temporary Other Hourly Rate/Salary _Final Reason for leaving?

$

per

(6)

Next Previous Employer

Telephone

Dates Employed Summarize the nature of the work performed and job responsibilities. From Mo/Yr Mo/Yr To Address Job Title Hourly Rate/Salary Starting Immediate Supervisor and Title

$

per Type of Employment Full Time Part Time

Temporary Other Hourly Rate/Salary _Final Reason for leaving?

$

per

5

COMMENTS (including explanation of any gaps in employment):

REFERENCES

List three business/work references who are NOT related to you and are NOT previous supervisors, but whom you have known at least one year. If not applicable, list three school or personal references that are not related to you.

Name Telephone Years Known In what capacity did this person observe you or your

work?

PROFESSIONAL LICENSES

List any professional license(s) and list state(s) in which licensed:

MEMBERSHIPS

List professional, trade, business, or civic associations (exclude memberships which would reveal sex, race, religion, national origin, age, color, or disability).

Organization Offices Held Dates

From (mo/yr) To (mo/yr)

SPECIAL ACCOMPLISHMENTS, PUBLICATIONS, AND AWARDS

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DRIVING HISTORY

DRIVER

LICENSE’S

STATE LICENSE NO. TYPE EXPIRATION DATE

DRIVING EXPERIENCE

CLASS OF EQUIPMENT _{(VAN, TANK, FLAT, ETC.)} TYPE OF EQUIPMENT _{FROM TO} DATES APPROX. NO. OF MILES _(TOTAL)

STRAIGHT TRUCK

TRACTOR & SEMI-TRAILER

TRACTOR-TWO TRAILERS

OTHER

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED) DATES NATURE OF ACCIDENT

(HEAD-ON, REAR-END, UPSET, ETC.) FATALITIES INJURIES

TRAFFIC CONVICTIONS & FOREITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)

LOCATION DATE CHARGE PENALTY

A.

H

ave you ever been denied a license, permit, or privilege to operate a motor vehicle? Yes No

B.

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

Yes No IF THE ANSWER TO EITHER A OR B IS YES. ATTACH STATEMENT GIVING DETAILS

OTHER INFORMATION

Have you ever been convicted of, or are you now under charges for, any misdemeanor or felony offense? Omit (1) traffic speeding fines. (A yes response will not necessarily disqualify you from employment.) Yes No

If checked yes, please explain below.

Are you bound by any non-solicitation/non-compete agreement? Yes No Have you ever applied here before? Yes No

If so: When? Position?

What prompted your application to PNW PUMPS?

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EMERGENCY CONTACT INFORMATION

1.

Name

Relationship

______________

Home Phone

_____________________

Work Phone

______________

Address

________________________________________________________

2.

Name

_________________________

Relationship

_______________

Home Phone

_____________________

Work Phone

_______________

Address

_________________________________________________________

3.

Name

_________________________

Relationship

________________

Home Phone

_____________________

Work Phone

________________

Address

_________________________________________________________

5711 Lacey Blvd SE, Suite 305 - POB 5355 Lacey Washington 98509 Tel: 360 628-8342 Fax: 877 655-9893 Email [email protected]

________________________________________________________

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INVESTIGATION AUTHORIZATION

By signing below, I hereby authorize Pacific NorthWest Pump Service & Sales to conduct an investigative report and/or

reference check concerning all statements contained in my application for employment; to interview all employers,

references, and other individuals and institutions to obtain information and opinions about me; and to conduct any

other investigation that it deems appropriate. Such investigation may include but is not limited to my education,

employment history (except my current employer if I have so indicated above), character, general reputation, credit

history, and driving, court, law enforcement, and military records. In the event that I am employed by Pacific NorthWest

Pump Service & Sales, I hereby authorize Pacific NorthWest Pump Service & Sales to answer any inquires regarding my

employment, conduct, qualifications, and reasons for leaving.

This release is executed with my full knowledge and understanding. In exchange for being considered for employment

I release Pacific NorthWest Pump Service & Sales,

LLC

its directors, officers, employees, and agents, as well as any

law enforcement agency, current or former employer, educational institution, credit agency, its representatives and any

third party persons, or any other individual providing information about me to Pacific NorthWest Pump Service & Sales

from any and all liability for damages of whatever kind, which may at any time result to myself, my heirs, family, or

associates because of compliance with this authorization or any attempt to comply with it.

Further, should I become employed by Pacific NorthWest Pump Service & Sales. I authorize Pacific NorthWest Pump

Service & Sales, to obtain this information once each year, and/or at the time the company is considering promoting me in its

employment, to verify that I have not committed any offenses that would make me ineligible for continued employment.

I hereby direct release of such information, upon request, to Pacific NorthWest Pump Service & Sales, LLC

Should there be any question as to the validity of this release, I may be contacted as

indicated below.

Print Name:

_______________________________________

Signed: _____________________________________

Date:

___________________

Telephone:

______________________________ 2

nd

_Telephone:

_{________________}

Social Security Number:

____________________

Date of Birth:

_________________

Witness (Print Name):

_____________________

Witness Signature: ________________________

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PLEASE REVIEW APPLICATION CAREFULLY. WE WILL NOT CONSIDER THIS APPLICATION IF

NOT COMPLETED IN FULL.

PLEASE READ THE FOLLOWING AND SIGN THE APPLICATION IN THE SPACES PROVIDED BELOW. IF

YOU HAVE ANY QUESTIONS, PLEASE SPEAK WITH THE HUMAN RESOURCES REPRESENTATIVE

BEFORE SIGNING.

I understand that employment by

is “at will.” This means that the employment

relationship can be ended by me or by Pacific NorthWest Pump Service & Sales,

at any time for any reason with or without

advanced notice and with or without cause. It also means that

may revise and make

exceptions to its policies, practices, handbooks, manuals, rules, procedures, and regulations, in whole or in part, at any time.

I further understand that acceptance of an offer of employment does not create a contractual obligation upon

to continue to employ me in the future or for any specific term.

If employed by

, I agree to comply with all safety and health rules, company policies and

procedures, and local, state, and federal laws pertaining to my employment. Although management makes every effort to

accommodate individual preferences, organizational needs may make the following conditions mandatory: overtime, or a

work schedule other than Monday through Friday or normal business hours. I understand and accept these as conditions of

my employment should I be hired.

I have reviewed this application carefully and I hereby affirm that my statements and answers to all questions on this

application are true and correct and that I have not knowingly withheld any fact or circumstance that, if disclosed,

would

affect my application unfavorably. I understand that any misstatement or omission of fact on this application may result in

my application not being considered, and, if employed, may result in my immediate dismissal.

I HAVE READ AND AGREE TO THE ABOVE TERMS AND CONDITIONS:

Print Name:

________________________________________

Signature of Applicant: ____________________________________________________

Date:

_________

Pacific NorthWest Pump Service & Sales,

Pacific NorthWest Pump Service & Sales,

Pacific

NorthWest Pump Service & Sales,

Pacific NorthWest Pump Service & Sales,

X

X

Release of Interest

Employer, prospective employer, or volunteer organization name:

Agent business name if acting on behalf of the company for employment purposes: This is an authorization of:

1. Employee – for release of my driving record for employment purposes, at my employer’s discretion for the full term of my employment; or

2. Prospective employee – for release of my driving record for employment purposes, not to exceed 30 days from date signed; or

3. Volunteer – for release of my driving record for a position applied for that requires me driving at the direction of the volunteer organization.

I, , am an employee, prospective employee, or volunteer of

Your name

the company named above and I request a copy of my official driving record in the state of Washington to my employer, prospective employer, volunteer organization, or their agent.

No employer, prospective employer, or their agent may use information contained in a driving record related to the sealed juvenile record of an employee or prospective employee for any purpose unless required by federal law. The employee or prospective employee must furnish a copy of the court order sealing the juvenile record to the employer, prospective employer, or their agent.

Employee / Prospective employee / Volunteer full name (First, Middle, Last) Date of birth (mm/dd/yyyy) WA driver license number

Employee / Prospective employee / Volunteer signature Date signed

The company listed below agrees to, and shall indemnify and hold harmless the state of Washington, Department of Licensing (DOL), the DOL Director, and all DOL employees from any and all suits at law or equity, and from any and all claims, demands or loss of any nature, including but not limited to all costs and attorney’s fees, arising from any incorrect or improper disclosure of individual names or addresses under this “Release of Interest;” any defects in any of Company’s procedures followed or omitted or arising from the failure of Company or its officers, employees, customers, contractors or agents to fulfill any of its obligations under this contract; or arising in any manner from any negligent act or omission by the company or its officers, employees, customers, contractors, or agents.

I hereby certify:

1. The company named below is an employer, prospective employer, or volunteer organization of the above- named individual.

2. The information contained in the abstracts of driver records obtained from DOL shall be used in accordance with the requirements and in no way violate the provisions of RCW 46.52.130. No information contained therein will be divulged, sold, assigned, or otherwise transferred to any third person or party. The abstracts of driver records shall be used exclusively for:

I affirm that I am a representative authorized to bind the company named below.

Company name Authorized representative name Title

Address

Date and place (city or county) signed Authorized representative signature

NOTE: The employer or prospective employer must maintain this record for a period of not less than two (2) years from the date of the request. Failure to obtain all signatures or misuse of records obtained from the State of Washington may result in prosecution under RCW 46.52.130.

DSC-425-020 (R/10/15)WAE

Pacific NorthWest Pump Service & Sales, LLC

Employee/Prospective employee/Volunteer: Print completed form and sign here

Pacific NorthWest Pump Service & Sales, LLC

Elizabeth Bigelow

Business Manager

PO BOX 5355 Lacey WA 98509 or physical - 5311 Suite 305 Lacey Blvd SE Lacey WA 98503

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EMPLOYMENT HISTORY CONTINUATION SHEET

Last Name First MI

Date of Application

Please place a number in the upper left-hand parentheses to designate the next previous employer, as continued from page 3 of the Employment Application, if this is your first continuation sheet, then number is 5.

( ) Next Previous Employer Telephone

Dates Employed Summarize the nature of the work performed and job responsibilities. From

Mo/Yr Mo/Yr To Address

Job Title

Hourly Rate/Salary _Starting

Immediate Supervisor and Title

$

per Type of Employment Full Time Part Time

Temporary Other Hourly Rate/Salary

Final Reason for leaving?

$

per

( ) Next Previous Employer Telephone

Dates Employed Summarize the nature of the work performed and job responsibilities. From

Mo/Yr Mo/Yr To Address

Job Title

Hourly Rate/Salary _Starting

Immediate Supervisor and Title

$

per Type of Employment Full Time Part Time

Temporary Other Hourly Rate/Salary

Final Reason for leaving?

$

per