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Louisville's Home Comfort and Energy Experts Since 1866

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A. N. Roth Company, LLC. is an equal opportunity employer and does not discriminate on the basis of race, color,
religion, sex,marital status, national origin, age, disability or citizenship.
Resumes or vitas may be attached, but not in lieu of completing this application.
A. N. ROTH COMPANY, LLC. APPLICATION FOR EMPLOYMENT




Position Desired : Full or Part Time : Date :
Personal Data
Name
(Print) Last First Middle
Present Address
Street Number City State Zip
How long have you lived there?
Years Months
Telephone No.
Home Work
Are you 18 years of age or older?
Previous Address
Street Number City State Zip

How long did you live there?
Years Months
Have you ever worked for this Company before?
If yes, please give dates and position:
Do you have any friends or relatives working here?
If yes, name and relationship:
Branch of Service Date Entered Date Discharged Type of Discharge Final Rank
Have you ever been convicted of a felony? NOTE: Answering "yes" to this question does not constitute an automatic bar to employment.
If yes, please give date and details:
EDUCATION:
CLICK the highest grade completed:
1 2 3 4 5 6 7 8 9 10 11 12 GED
College
1 2 3 4 5
Graduate School
1 2 3 4 5
Schools Grad? Name & Location Dates Attended Miscellaneous Information
High School
Major emphasis
Semester/Quarter Hrs. Major/Minor Degree
Junior/Comm.College(s)
College(s) and/or University(s)
Graduate and/orProfessional
Other EducationVocational Tech.
RECORD OF PREVIOUS EMPLOYMENT

Please list the names of your present or previous employers in chronological order with present or last employer listed
first. Besure to account for all periods of time including military service and any period of unemployment. If self-employed, give firmname and supply business references.

Present or last employer
Employed From Pay Start $ State your title and describe your work.
Address
City, State, Zip Code
To (mo/yr) Final $ Name and Title of last supervisor Reason for leaving
Telephone
Previous employer
Employed From Pay Start $ State your title and describe your work.
Address
City, State, Zip Code
To (mo/yr) Final $ Name and Title of last supervisor Reason for leaving
Telephone
Previous employer
Employed From Pay Start $ State your title and describe your work.
Address
City, State, Zip Code
To (mo/yr) Final $ Name and Title of last supervisor Reason for leaving
Telephone
Previous employer
Employed From Pay Start $ State your title and describe your work.
Address
City, State, Zip Code
To (mo/yr) Final $ Name and Title of last supervisor Reason for leaving
Telephone
Have you ever been terminated or asked to resign from any job?
If yes, please explain the circumstances:
Please explain fully any gaps in your employment history:
May we contact your current Employer? If no, please explain:
Would your current or past employers identify you by a different name? If yes, please list:
BUSINESS REFERENCES
Name Occupation Address (Street, City, State, Zip) Telephone Number Number of Years Known
PREVIOUS EXPERIENCE
Please indicate your previous experiences, which you feel are relevant to the position for which you are applying:

IF DRIVING IS PART OF THE DUTIES OF THE JOB FOR WHICH YOUR
ARE APPLYING, PLEASE FILL OUT THE FOLLOWING INFORMATION:

Do you have a current driver's license?
State: License No: Expiration Date:
Has your driver's license ever been suspended or revoked?
If yes, please explain the circumstances:
Do you have personal automobile insurance? Name of Insurance Company:
Has your personal automobile insurance ever been cancelled?
If yes, please explain the circumstances:
Have you ever been cited for driving under the influence (DUI) or drifiving while intoxicated (DWI)?
If yes, please explain the circumstances and outcome:
Please list all moving traffic violations in the last five (5) years:
Offense Date Location
Offense Date Location
Offense Date Location

Offense Date Location

A. N. Roth Company, LLC. is an Equal Opportunity Employer. A. N. Roth Company, LLC. does not discriminate in employment and no question on this application
is used for the purpose of limiting or excluding any applicants consideration for employment on a basis prohibited by local, state, or federal law.



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