Masi Contracting Inc.
dba

Acorn Electric

"An Equal Opportunity Employer"

Application for Employment

Today's Date: (MM/DD/YYYY)
First name:         Middle name:
Last name:  
Home telephone number: (###-###-####)
Present address   Street:
                              City:   State: CT - Connecticut NY - New York
                      Zip Code:
Social Security Number: (###-##-####)
Are you a citizen or permanent resident of the United States? Yes No
If "No", under what authority will you be working in the U.S.?
Are you over age 16? Yes No
Position applying for: Full Time Part Time Temporary
If you are qualified to do any other work than the position you are applying for, please explain:
Date available for work:     Salary requirements:
Please write a brief statement in which you express why you feel qualified for the job and what your career goals are:
Education - Please list QED, High School, College, State Certificates and other schools attended. Please note if you graduated and if you received a degree or certificate.
Employment Record - Starting with PRESENT or MOST RECENT, list your last three employers. Please include self-employment, summer and part time jobs if applicable.
Company Name: Street Address:
City, State and Zip Code:
Position, title and department held: Salary: Dates employed: Supervisor's name and telephone number: Reason for leaving:

Company Name: Street Address:
City, State and Zip Code:
Position, title and department held: Salary: Dates employed: Supervisor's name and telephone number: Reason for leaving:

Company Name: Street Address:
City, State and Zip Code:
Position, title and department held: Salary: Dates employed: Supervisor's name and telephone number: Reason for leaving:

Special Skills - Please list any skills that you have not disclosed as of yet (typing - WPM; Excel; Access; Word; Power Point; Foreign Languages spoken; Commercial Driver's License, etc.)
Personal Information/References - Give the names of two people not related to you, with whom you are acquainted and whom we may contact as to your character, habits and abilities. (Please do not give the names of former employers, relatives or minors.)
Name: Address: Phone number: Years known:

Name: Address: Phone number: Years known:

Please answer the following questions. Your answers will be held in strict confidence, except as needed to process your application.
1. Have you ever been convicted of a criminal offense?
2. Have you ever pleaded anything but "not guilty" to any criminal charge?
3. Are there any criminal charges currently pending against you?
4. Do you currently use illegal drugs?
5. Has your driver's license ever been suspended or revoked in any state?

Employment At Will and Background Check

I understand that as part of my education and past employment verification, Acorn Electric/Masi Contracting Inc. may contact any of my educational institutions and previous employers for information regarding my relationship with them. I hereby authorize them to disclose any relevant information to Acorn Electric/Masi Contracting Inc. as may be necessary to process my application of employment. I hereby further agree that a copy of this authorization shall be effective and shall serve the same purpose as the original.

I understand that if an offer of employment is made to me, it may be conditional upon a satisfactory health evaluation by a medical doctor selected by Acorn Electric/Masi Contracting Inc. to which I agree. I further agree to complete a health evaluation form.

Acorn Electric/Masi Contracting Inc.'s relationship with its employees is and always will be one of voluntary employment "at will". Neither the employee nor Acorn Electric/Masi Contracting Inc. has entered into a contract of employment, either expressed or implied. This means that Acorn Electric/Masi Contracting Inc., or the employee is free to terminate the employment relationship at any time.

Employment at Acorn Electric/Masi Contracting Inc. is voluntarily entered into for no stated term or period of time. Acorn Electric/Masi Contracting Inc. has the right to terminate any employee at any time, with or without cause being shown.

I certify that all statements made by me on this application are true and complete, and I have withheld nothing that would, if disclosed, adversely affect this application. Making false statements on this application may be grounds for termination.