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

    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: