Century Concrete

Self-Identification (Voluntary)
Race or Ethnicity Identity	Hispanic or Latino Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. White (not Hispanic or Latino) White (not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East or North Africa. Black or African American (not Hispanic or Latino) Black or African American (not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander (not Hispanic or Latino) Native Hawaiian or Other Pacific Islander (not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa or other Pacific Islands. Asian (not Hispanic or Latino) Asian (not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam. American Indian or Alaskan Native (not Hispanic or Latino) American Indian or Alaska Native (not Hispanic or Latino) - A person having origins in any of the original peoples of North and South America (including Central America) and who maintain tribal affiliation or community attachment. Two or more races (not Hispanic or Latino) Two or more races (not Hispanic or Latino) - All persons who identify with more than one of the above races. I do not wish to self-identify
Gender	Male Female I do not wish to self-identify
Veteran Status	I am a Veteran of the U.S. Armed Services If yes, what branch? I am a Protected Veteran Protected veteran means a veteran who may be classified as an active duty wartime or campaign badge veteran, disabled veteran, Armed Forces service medal veteran or recently separated veteran Active duty wartime or campaign badge veteran means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense. Disabled veteran means (1) a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs, or (2) a person who was discharged or released from active duty because of a service-connected disability. Recently separated veteran means a veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval or air service. Armed Forces service medal veteran means any veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985 (61 FR 1209, 3 CFR, 1996 Comp., p. 159). I am NOT a Protected Veteran I do not wish to self-identify

Hispanic or Latino

Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.

White (not Hispanic or Latino)

White (not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East or North Africa.

Black or African American (not Hispanic or Latino)

Black or African American (not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa.

Native Hawaiian or Other Pacific Islander (not Hispanic or Latino)

Native Hawaiian or Other Pacific Islander (not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa or other Pacific Islands.

Asian (not Hispanic or Latino)

Asian (not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.

American Indian or Alaskan Native (not Hispanic or Latino)

American Indian or Alaska Native (not Hispanic or Latino) - A person having origins in any of the original peoples of North and South America (including Central America) and who maintain tribal affiliation or community attachment.

Two or more races (not Hispanic or Latino)

Two or more races (not Hispanic or Latino) - All persons who identify with more than one of the above races.

I do not wish to self-identify

Applicant Information
Date	11/27/2024
Position you are applying for
Preferred Location	Virginia Beach, VA Ashland, VA Springfield, VA
First Name
Middle Name
Last Name
Current Street Address
City
State
Zip
Mobile Phone Number
Secondary Phone Number
Email Address
Are you legally authorized to work in the United States?	Yes No Note: If yes, verification will be required upon hire.
Date of Birth
Place of Birth
Emergency Contact Name
Emergency Contact Phone Number
Relationship to applicant
Type of employment desired	Full-Time Internship
Salary Requirements
Date available to begin working
Do you have geographic restrictions in work location?	Yes No If yes, describe
Are you willing to travel?	Yes No
Were you previously employed by Century Concrete?	Yes No If yes, dates employed: - If yes, Position/Title/Supervisor Name: If yes, reason for leaving:
Have you ever been convicted of a felony?	Yes No If yes, explain fully and include the dates of the conviction, court, state, county, nature of crime and circumstances involved.

Reference #1
Name
Relationship to applicant
Phone Number
Email

Reference #2
Name
Relationship to applicant
Phone Number
Email

Reference #3
Name
Relationship to applicant
Phone Number
Email

High School
High School (Institution Name)
City, County and State
Did you graduate?	Yes No
Highest level completed

Century Concrete General Application

I. Instructions

II. Applicant Self-Identification (Voluntary)

III. Applicant Information

IV. List three professional references who are not relatives.

V. Education

VI. Skills & Certifications

VII. Employment History

VIII. Attachments

IX. Authorization & Consent

College/University
College/University (Institution Name)
City, County and State
Did you graduate?	Yes No
Highest level completed
Degree

Graduate or Professional
Graduate or Professional (Institution Name)
City, County and State
Did you graduate?	Yes No
Highest level completed
Degree

Training/Vocational Program
Training/Vocational Program (Institution Name)
City, County and State
Did you graduate?	Yes No
Highest level completed
Major/Field of study

Other (G.E.D., etc.)
Other (G.E.D., etc.) (Institution Name)
City, County and State
Did you graduate?	Yes No
Highest level completed
Major/Field of study

Skills & Certifications
List any office equipment you have experience operating.
Specify computer software applications with which you have a working knowledge, indicating proficiency.
List foreign languages in which you have working skills indicating level of fluency (check all applicable boxes)	Speak Read Write Speak Read Write Speak Read Write Speak Read Write
List current professional certificates, licenses, registrations and current job-related memberships in professional organizations (include state, branch, certificate number and expiration date).
CPR Certified	Yes No
OSHA 10	Yes No
OSHA 30	Yes No

Employment #1
Company Name
Address, City, State, Zip Code
Type of Business
Position Held
Type of Employment	Full-Time Part-Time Other
Employment Dates	-
Beginning Salary
Ending Salary
Supervisor's Name and Title
Supervisor's Phone Number
Describe your major responsibilities
Reason for leaving
May we contact this employer?	Yes No

Signature
Electronic Signature
Date