Capital Academy Name* First Last Home Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Cell Phone Number*Other PhoneEmail* Are you 18 years or older?*YesNoAre you lawfully authorized to work in the U.S?*YesNoWhat position are you applying for?*If applying for a Driver position, please select Class: Class A Driver Class B Driver Upload resume (If applicable)Who referred you to Capital?*Current Capital EmployeeCapital BillboardFriendCapital Social MediaOtherIf referred by a current employee, please list name:If applying for a Laborer, Operator, or Driver position you must be able to lift up to 50 lbs. on a regular basis, must be able to stoop, bend, and work in extreme temperatures. Can you perform these essential job duties with or without an accommodation?*YesNoList all States in which you have held a driver’s license (at least 3 years must be shown). Please list State, License No., Class, Endorsements, and Expiration Date.1. Have you ever been denied a license or privilege to operate a motor vehicle?*YesNo2. Has any license, permit or privilege ever been suspended or revoked?*YesNo3. Have you ever been disqualified to drive a Commercial Motor Vehicle under the Federal Motor Carrier Safety Regulations?*YesNoIf your answer to 1, 2, or 3 above is yes, please explain:Driving Experience - Please list Class of Equipment (Straight Truck, Tractor Trailer, Other), Type (dump, flat bed, etc.), Dates, Approx. MilesSafety Record - List all accidents for the past 5 years. Please list Dates, Describe Accident, Injuries or Fatalities?Special Skills (heavy equipment operator, mechanical maintenance, construction, forklift, etc.) - Please list Dates, Type of Skill/ExperienceEducation - Please list Name of School, Location, Dates Attended, and DegreeName of Present or Last Employer*Please include your employment for the past 10 years.Job Title*Phone*Address* Street Address City State / Province / Region ZIP / Postal Code Starting Date* Date Format: MM slash DD slash YYYY Leaving Date* Date Format: MM slash DD slash YYYY Reason for Leaving*Ending Wage*May we contact to verify your employment?*YesNoPhonePrevious EmployerAddress Street Address City State / Province / Region ZIP / Postal Code Starting Date Date Format: MM slash DD slash YYYY Leaving Date Date Format: MM slash DD slash YYYY Reason for LeavingEnding WageMay we contact to verify your employment?YesNoPrevious EmployerJob TitlePhoneAddress Street Address City State / Province / Region ZIP / Postal Code Starting Date Date Format: MM slash DD slash YYYY Leaving Date Date Format: MM slash DD slash YYYY Reason for LeavingEnding WageMay we contact to verify your employment?YesNoReferences - List three professional references (do not list relatives). Please list name, street address, and phone number.*“I certify that I have read and understood the employment application, and I am submitting this application for the sole purpose of seeking employment with Capital. It is agreed and understood that Capital, or its agents may investigate my background and employment history, whether same is of record or not. I understand that this information will be used for the purpose of determining my eligibility for employment with Capital. I authorize, without reservation, any party or agency contacted by Capital to furnish requested information concerning my work history and character. I release all employers, USIS, and other persons named herein from all liability for damages due to furnishing such information. I certify that this application was completed by me and all answers I have given are truthful to the best of my knowledge. I understand that any misrepresentations or omissions may result in my rejection for consideration or dismissal. Copies of this document carry the same authority as the original document. I agree to furnish additional information, i.e. social security number, and complete examinations and drug tests as may be required.”I agree to the above authorization*I agreeYour Name*Date* Date Format: MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.