Employee Information Sheet - NEW HIRE Employee Name Date of Birth Social Security # Present Address Phone Number Cell Number Race Union Affiliation: Years of Membership: Maritial Status:SingleMarriedSeperatedDivorcedWidowed Sex:MF In case of emergency-who can we contact? Please use another number than your home number Name Phone Address Relationship to you Your email address Please list your last 3 employers: Employer/Address to from work performed 1 2 Add Another Work Experience Name: Location (Address, City, State, Zip): Phone: Date Started Starting Position Title Ending/Current Position Title Date Left Supervisor Name & Title Reason for Leaving Responsibilities: May we contact this employer? YesNo If no, explain: Please provide a copy of your Drivers License and Social Security Card and OSHA 10 Card Economy Paving Co.,Inc. is an Equal Opportunity Employer Have you received COMPENSATION OR DISABILITY BENEFITS? YESNo If YES- Please describe the nature and extent of your previous injury: Do you have any present disabilities or limitations? YesNo if yes, please describe List any other serious injuries or illness which may affect your ability to perform your job duties: Do you have a valid drivers license: YesNo Economy Paving reserves the right to request a Drivers License Abstract at our discretion with regards to each employee's license. Class of license: State of license: license Number: Date of Expiration: A separate employee eligibility verification form I-9 should be submitted with this form I have received and read a copy of the standard employment packet. If I have any questions regarding information included in the packet I will contact Economy Paving Co. Inc. I have received and read a copy of the standard employment packet. If I have any questions regarding information included in the packet I will contact Economy Paving Co. Inc. I realize the failure to comply with them could result in termination of employment. I realize the failure to comply with them could result in termination of employment. Economy Paving Company, Inc. is an Equal Opportunity Employer Providing The Information Below Is Optional Name: Sex: Race: By adding the date and my name to the signature line below, I certify that the answers given herein are true and complete to the best of my knowledge. I realize that any miss representation in the information submitted or any intention of withholding of essential information called for in this form may result in my immediate dismissal. Date: Electronic Signature: