Job application form

First name(required)

Last name(required)

Any other name used

Current Address(required)

Previous Address

Who referred you to the company?

Are you at least 18 years of age?(required)

Yes No

If no, give age

Have you ever committed or been convicted of a crime other than a minor traffic violation?(required)

Yes No

Are there any charges pending against you that may result in a criminal conviction other than a minor traffic violation?(required)

Yes No

If yes, please provide the date, offense and punishment/outcome

Explanatory details

Education

Highest level of completed education(required)

Grade School High School College Trade School

Name of most recent school attended(required)

Year you left(required)

Did you graduate?(required)

Yes No

Do you plan to attend school while working for the Company?(required)

Yes No

If yes, where and what subject?

Job Sought

Position Applied for(required)

Desired Salary(required)

Choose one(required)

Hourly Weekly Monthly

Are there any times of the day, days of the week or days during the year you will be unable to work?(required)

When are you available to start working?(required)

If hired, how will you get to work?

For Clerical applicants ONLY, please list your WPM and familiar computer software

U.S. Military Service

Present Classification(required)

Are you a member of National or State Guard or Active Reserve?(required)

Yes No

Branch

Dates served

Additional Training/Skills

Special certifications, licenses or registrations related to the job you're applying for

Do you have any disciplinary action pending concerning your professional license or certificate?(required)

Yes No

If yes, explain

Has your license ever been suspended or revoked?(required)

Yes No

If yes, explain

Describe any other job relevant or general interest skills

Employment

Have you ever worked for the Company before?(required)

Yes No

If yes, when?

Have you ever applied to work the the Company before?(required)

Yes No

If yes, when?

Do you know anyone working for the Company now or in the past?(required)

Yes No

If yes, list their names and your relationship to them

Do you intend to work anywhere else in addition to working at the Company?(required)

Yes No

If yes, where?

Are you presently employed?(required)

Yes No

If yes, name, address and phone number of current employer

Why do you want to change jobs?

References

Please list three people, professionals, or other persons to whom you could turn for help. Do not list relatives, former employers or employees of the Company.

1

Name, Occupation, Address & Phone Number

How long known & nature of relationship

2

Name, Occupation, Address & Phone Number

How long known & nature of relationship

3

Name, Occupation, Address & Phone Number

How long known & nature of relationship

Work History

Name of present or most recent employer(required)

Address(required)

Telephone #(required)

Nature of work(required)

Starting date(required)

Leaving date(required)

Starting wage

Ending wage

Reason for leaving(required)

Name of second employer

Address

Telephone #

Nature of work

Starting date

Leaving date

Starting wage

Ending wage

Reason for leaving

Name of third employer

Address

Telephone #

Nature of work

Starting date

Leaving date

Starting wage

Ending wage

Reason for leaving

Please give any additional information you feel may help us in considering this application

AGREEMENT (Read Carefully)

I, the undersigned, agree to the following; (1) that all information supplied in this application and any attached resume is true and correct and that any false or misleading information furnished by me regarding my application will be sufficient cause for rejection of this application or immediate dismissal if employed by the Company; (2) That, if such is required, I will take a drug/alcohol screen test during the application process or during employment if hire, and if required, will submit to a physical examination after a conditional offer of employment, if one is made, or during employment if hired and will permit the results to be released to the Company and to release all persons and companies from any liability arising out of such examination or testing; (3) That during my employment with the Company, if hired, I will report to the Company any drugrelated criminal conviction within five days of conviction; (4) That if hired, I agree to abide by and observe all Company rules and regulations and agree that my employment is at-will and can be terminated with or without cause and with or without notice at any time at either the option of the Company or the employee and that those terms can only be modified by the Company, in writing, provided that such writing specifically acknowledge that it is a modification of this agreement and is signed by the President of the Company; (5) That no supervisor, agent, representative or employee of the Company has now or has had in the past any authority to enter into any agreement or employment for a specified period of time, or to make any agreement which is contrary to or a modification of the above terms, nor can any policies of the Company, either written or oral, modify the above terms; (6) That if hired, I may be on a six month introductory period during which time I may be discharged without recourse; and (7) That the use of this application form does not indicate there are any positions open and does not in any way obligate the Company or its associated Companies. I agree that, except for certain exceptions described below, all disputes, claims and/or causes of action arising out of or related in any way to my employment are subject to final and binding arbitration in accordance with the most current rules of the American Arbitration Association. Interpretations will be according to Louisiana law, unless federal law prevails. In either case, all discussions and proceedings will be in Lafayette, Louisiana. “Disputes, claims and/or causes of action” includes, but not limited to, claims alleging discrimination, sexual harassment, failure to hire, failure to promote, wrongful termination or discharge, and personal injury. “Arising out of or related in any way to your employment” includes, but not limited to, claims against The Cajun Company, Inc. or subsidiary corporations, any project owner, engineer or contractor for whom or with whom TCCI has done or may be doing work at any time during your employment and any person, company or entity to whom TCCI owes any duty of indemnity. I understand this agreement is intended to apply only to causes of action which might be brought by me or someone acting on my behalf, in a court of law. By way of example only, such causes of action include claims under federal, state, and local statutory or common law such as the Age Discrimination in Employment Act, Title VII of the Civil Rights Act of 1964, as amended, including the amendments of the Civil Rights Act of 1991, the Americans with Disabilities Act, the Equal Pay Act, the law of contract and the law of tort. This agreement does not and is not intended to prevent me from filing for workers’ compensation or unemployment compensation, nor is it intended to prevent me from filing charges or complaints with the National Labor Relations Board, the Federal Equal Employment Opportunity Commission, and the Federal Occupational Safety & Health Administration, other federal, state or local administrative agencies having similar responsibilities. I understand that acceptance of the terms and conditions of this Arbitration section is a condition of my employment with The Cajun Company, Inc. Any provisions or part thereof of these policies held to be void or unenforceable under any applicable law shall be stricken and all remaining provisions shall continue to be valid and binding.

RELEASE (Read Carefully)

I, the undersigned, authorize all educational institutions which I have attended, all branches of U.S. military service in which I have served, all of my former and present employers, all credit bureaus, all court systems and all of the representatives of those organizations to furnish The Cajun Company, Inc. or its subsidiaries, associated companies or representatives any and all information concerning my education, military service, former employment, credit history and/or criminal convictions. In addition, I hereby agree to hold harmless and to release all of said organizations, institutions, services, employers, bureaus, courts and representatives from any and all claims that I may have, or which may arise against ant and/or all of them, including The Cajun Company, Inc., its subsidiaries, associated companies and representatives as a result of their furnishing information to the Company, its subsidiaries, associated companies or representatives.

ELECTRONIC SIGNATURES (Read Carefully)

Any signature (including any electronic symbol or process attached to, or associated with, a contract or other record and adopted by a Person with the intent to sign, authenticate or accept such contract or record) hereto or to any other certificate, agreement or document related to this transaction, and any contract formation or record-keeping through electronic means shall have the same legal validity and enforceability as a manually executed signature or use of a paper-based recordkeeping system to the fullest extent permitted by applicable law, including the Federal Electronic Signatures in Global and National Commerce Act, the New York State Electronic Signatures and Records Act, or any similar state law based on the Uniform Electronic Transactions Act, and the parties hereby waive any objection to the contrary.

I have read and understand the above agreements(required)

Yes No

Date(required)

eSignature(required)