New Hire Employment Application

Section #3
EMERGENCY INSTRUCTIONS

In case of emergency contact:
In case of emergency contact*
First Last
Phone Number*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Are there any other emergency instructions, circumstances, medical needs, allergic responses or procedures the company should know?*
HEALTH AND SAFETY
Have you ever have any injury or injuries on the job?*
- Yes
- No
List*
Injury Date of Injury Employer Body Part Affected Cause Amount of the Lost Time Any permanent Disability Was Workers' Comp. Claim Filed?

(if applying for a job in NY or IL leave workers; comp question, line G, blank)
Do you have or have you had other injuries or illnesses not on the job (home, auto, sports, hunting, etc.) that have resulted in the hospitalization, surgery, or lost work time*
- Yes
- No
List*
Injury Date of Injury Body Part Affected Cause Days in Hospital Days of Lost Work Time Have you recovered?
Are you taking any longer term (more than 30 days) prescribed medication?*
- Yes
- No
List*
Type of Medication Purpose Side Effects
Do you have or have been diagnosed as having any illness or injury for which you are not seeking treatment?*
- Yes
- No
If YES, please describe:*
COMMENTS

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Section #4
MASTER DATA SHEET

NEW EMPLOYESS
Additional Federal Tax Withholding:
or
Additional State Tax Withholding:
or
PAYROLL DIRECT INFORMATION AND CHECK STUB DELIVERY REQUEST
Employee Name
First Last
Name of Bank
Routing Number
(First set of numbers at bottom of check)
Account Number
(Second set of numbers at bottom of check)
Account Type
- Checking Account (Copy of or voided check required)
- Savings Account (Copy of or deposit slip required)
PAYROLL CHECK STUB DELIVERY REQUEST
Please check one of the options below.
- Please email my check stub to the email address blow.
- Please mail me check stub.
Note that email allows for immediate pay stub notification. Mailed stubs do take a few days longer than the email service.
Email
ATS CONSTRACTION 401K VOLUNTARY PROGRAM
Please choose one of the options below:
- I would NOT LIKE to be enrolled in the ATS Construction 401K program at this time
- I hereby ACCEPT and would like to participate in the 401K Paycheck Contribution plan.

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Section #1

INCIDENT	CITY/STATE	CHARGE

NAME	ADDRESS/PHONE	YEARS KNOWN/RELATIONSHIP

Injury	Date of Injury	Employer	Body Part Affected	Cause	Amount of the Lost Time	Any permanent Disability	Was Workers' Comp. Claim Filed?

Injury	Date of Injury	Body Part Affected	Cause	Days in Hospital	Days of Lost Work Time	Have you recovered?