JOB APPLICATION

Brookside Stone LLC

174 Doss Hollow, Evarts, Kentucky 40828

(606) 273-3388

Brookside Stone LLC is an equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state or federal law. Should an applicant need reasonable accommodation in the application process, he or she should contact a company representative.

Please fill out all sections below:

Applicant Information

Applicant Name

Address

Phone

Email

Date of Application

Employment Position Position(s) applying for: (full-time)

How did you hear about this position?

If needed, are you available to work overtime?

On what date can you start working if you are hired?

Do you have reliable transportation to and from work?

Salary desired:

Personal Information

Have you ever applied to or worked for Brookside Stone LLC before?

Yes

No

If Yes, when?

Do you have any friends, relatives or acquaintances working for Brookside Stone LLC?

Yes

No

If yes, state name & relationship:

Are you 18 years of age or older?

Yes

No

Are you a U.S. citizen or approved to work in the United States?

Yes

No

What document(s) can you provide as proof of citizenship or legal status?

Will you consent to a mandatory controlled substance test?

Yes

No

Have you ever been convicted of a criminal offense (felony or misdemeanor)?

Yes

No

If yes, please state the nature of the crime(s), when and where convicted and disposition of the case:

(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)

Job Skills/Qualifications

Please list below the skills and qualifications you possess for the position for which you are applying:

(Note: Brookside Stone LLC complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions.)

Education and Training

Please list your complete education and training information below, including High School, College/University and Vocational School/Specialized Training. Include the following: School Name, Location, Year Graduated and Degree(s) Earned for each.

Military

Are you a member of the Armed Services? If No, skip to 'Previous Employment' below.

Yes

No

What branch of the military did you enlist?

What was your military rank when discharged?

How many years did you serve in the military?

What military skills do you possess that would be an asset for this position?

Previous Employment

Please list the following for each employer: Employer Name, Job Title, Supervisor Name, Employer Address, Employer Telephone, Dates Employed, Reason for Leaving

References Please provide 2 personal and professional references below:

Reference 1 - Name, Relationship and Contact Information

Reference 2 - Name, Relationship and Contact Information

Additional Information

Do you have a Commercial Driver License? (CDL) class A or B? Please indicate below:

Yes

No

Class A CDL

Class B CDL

Are you physically capable to lift heavy objects for extended periods?

Some positions may require overnight stays. Are you available to work out of town overnight?

Do you have a valid Driver's License?

At-Will Employment

The relationship between you and the Brookside Stone LLC is referred to as "employment at will". This means that your employment can be terminated at any time, for any reason, with or without cause, with or without notice, by you or the Brookside Stone LLC. No representative of Brookside Stone LLC has authority to enter into any agreement contrary to the foregoing "employment at will" relationship. You understand that your employment is "at will", and that you acknowledge that no oral or written statements or representations regarding your employment can alter your "at-will employment" status, except for a written statement signed by you and either our Executive Vice-President/Chief Operations Officer of the Company's President.

Applicant's Signature and Date

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.