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Applicant Information

Last Name: *
First Name: *
Middle Name: *
Phone: *
Alternate Phone:
Email: *
Emergency Contact Name: *
Emergency Contact Phone: *
Emergency Contact Relationship: *
Are you at least 18 years old?: *
Are you legally authorized to work in the US?: *
Are you a veteran?:
Have you ever been convicted of a crime?: *
If yes, please explain.:

Skills and Qualifications

Street: *
City: *
State: *
Zip Code: *
CRC Level: *
General labor experience (check all that apply): *
Construction Experience (check all that apply): *
Skilled trade experience (check all that apply): *
PPE you own or can purchase (check all that apply): *
Foreign languages spoken:
Certifications and Licenses:

Work Requirements

Expected Salary: *
Type of work (Please select all available): *
Shifts available (Please select all available): *
What is your method of transportation?: *
Do you have a valid driver's license?: *


Highest level of education completed: *
Institution (Name and Address):
Degree or area of study:

Current/Most Recent Employment

Company Name: *
Job Title: *
Dates employed: *
Ending Salary:
Reason for leaving: *
May we contact this employer?: *

Professional References

Supervisor Reference 1 (Name): *
Supervisor Reference 1 (Relationship): *
Supervisor Reference 1 (Phone): *
Supervisor Reference 2 (Name): *
Supervisor Reference 2 (Relationship): *
Supervisor Relationship 2 (Phone): *

Attachment Information

Resume: *

Contact us

Roebuck Staffing Co.
300 E. Arlington Blvd.
Suite 3A
Greenville, NC  27858