First and foremost, we reserve the right to send you home if your appearance, in our opinion, does not meet our standards.
Uniform shirts: We took the first step when we furnished uniform shirts for you. Please see that you are always in a clean uniform shirt when you come to work.
Pants: We require black, khaki, or navy slacks. We allow solid color "shorts" (they must be not more than 3" above the knee). We do not allow sweats, leotards, spandex, or other tight or form clinging clothing. No jeans are allowed.
Shoes: No open-toed shoes, sandals, high heels, or high-topped fashion boots. Sneakers, hiking boots, or regular shoes are fine.
Makeup and Jewelry: No '"exotic" make up is allowed. No earrings for male employees, no eye, nose, or tongue studs or rings for anyone while on duty. If you just got pierced and cannot take the ring out for a short time, then you must wear a bandage that entirely covers the area. Loose jewelry is not allowed for safety reasons. No sunglasses are to be worn while working inside.
Hygiene: Always arrive clean and well-groomed. Well kept beards, goatees, or mustaches are allowed, but you must be clean-shaven on the parts of your face where the above is not grown.
Hat: No stocking hats. Baseball caps (having a gas çompany logo) are allowed, however, the bill must always face forward.
I have read the above policies, understand their meaning, and consent to these policies. Please print and save an employee copy for your records.
Employee Information Form
Social Security Number:
Date of Birth:
Phone number: Email Address:
Emergency Contact Name and Phone Number:
Pay Rate: Exemptions: Federal: State:
Type of Pay:
Increase: From: to
Date of Last Increase:
Post-Job Offer Medical Questionnaire
Applicant's Name: Job Title:
Hiring Department- Describe any unusual physical demands of the job:
Notice to applicants: ln compliance w¡th the Americans with Disabilities Act of 2008 (ADA), you have received a conditional offer of employment. This medical history statement is required of all offerees. The answers to the medical history statement and any medical examination will be kept confidential and in separate files in compliance with the ADA requirements. The job offer which y0u have received is conditioned upon satisfactory c0mpletion snd review 0f this medical statement and any required medical examination or follow up.
Genetic Information Nondiscrimination Act (GINA) of 2008: Title II of the GINA prohibits employers and other entities by GINA Title II from requesting or requiring genetic information of employees or their family members. In order to comply with this law, we are asking that you not provide any genetic information when responding to a request for medical information. "Genetic information," as defined by GINA, includes an individual's family member's genetic tests, the fact that an individual or an individual's family members sought or received genetic services, and genetic information of a fetus carried by an individual's family member, and genetic information of an embryo lawfully held by an individual or family member receiving assistive reproductive services.
Applicant Affirmation: I herewith affirm that the employer has made me an offer of employment, conditioned on the satisfactory completion of this questionnaire, and any required medical examination or follow-up. The purpose of this inquiry is: to determine whether I currently have the physical qualification necessary to perform the job that has been offered; to determine whether and what accommodations may be necessary; and to determine where I can perform essential functions of the job, without posing a significant direct threat to the health and safety of myself and others. This information will be kept strictly confidential in a separate medical file, apart from my personnel file. I hereby affirm that the questions in the medical questionnaire have not been asked of me by anyone with the employer until after I have signed this statement and been offered a conditional job.
- Do you have any physical or mental disease, disorder, defect, handicap, disability, deformity or abnormality, or any other condition (including alcoholism or any drug use or dependency) which might affect your attendance at work or ability to do this job? If yes, please explain fully and state what reasonable accommodation would permit you to perform the job satisfactorily:
- Have you within the last two years had an illness that caused you to be absent from work or school for more than one week? If yes, please explain:
- Do you have or have you ever had reactions to chemicals for which you sought medical attention? If yes, please explain:
- Have you ever had or been treated for any of the following conditions or diseases?
- Herniated Disc
- Knee injury
- Surgical removal of a disc or spinal fusion
- Back injury
- Hernia or rupture
- Neck injury, pain or problems
- Chest pain
- Shoulder injury
- Arthritis or rheumatism
- Arm/hand injury
- Wrist problems, including Carpal Tunnel Syndrome
- Broken bones
- Ankylosis (immobility) of ankles, knees, hips
- Head injury
- Loss of sight or hearing
- Epilepsy, fainting spells, or dizziness
- Heart disease
- Numbness, tingling or swelling of hands or feet
- Frequent headaches or migraines
- High blood pressure
- Respiratory problems such as asthma, allergies, or lung disease
- Depression, anxiety, or other diagnosed mental health disorders
- Have you ever refused surgery?
- If you answered "Yes" to any of the above, please explain in detail, including dates, body parts, and treating physicians:
- Have you ever been hospitalized for any of the above conditions?
- If "Yes," for which conditions?
- Have you ever had an MRI?
- If "Yes," please explain:
- Have you ever been forced to give up a job for health reasons?
- If so, please explain:
- Have you ever been hurt on the job or filed a workers' compensation claim in the past?
- If "Yes," how many times?
- If "Yes," in what years?
- If "Yes," was any claim denied?
- If "Yes," how many claims were denied?
- Has a doctor given you an impairment rating? If so, please provide the reason and the percentage of impairment. If you have not been given an impairment rating, state none:
- Have you ever been refused a driver's license due to your health? If yes, please explain:
- How many pounds can you lift comfortably without help?
- Are you taking any prescribed drugs that would interfere with your job performance? If yes, please list the medications:
The above statements are true to the best of my knowledge. I understand that any misstatement of fact is grounds for disciplinary action up to and including termination. I further understand that any willful misrepresentation of any medical condition can serve to bar any future claim for workers' compensation benefits.
Printed Name: Date:
Georgia New Hire Report
Georgia New Hire Report
Send the completed form to: Georgia New Hire Reporting Program
PO Box 38480, Atlanta, GA 30334-0480.
Fax form to: 1-888-541-0521
For more information: 1-888-541-0469
Employer Name: Geo H. Green Oil, Inc.
Address Line 1: 41 Dodd Street
Address Line 2: PO Box 127
City/State/Zip Code: Fairburn, Georgia 30213
Contact Phone/ Name: Cindy O'Dell 770-964-6125
Medical Insurance Coverage Available: Yes (After 90 days of employment)
Social Security Number:
Date of birth :
Date of hire:
State of hire:
I have read all of the above policies, understand their meaning, and consent to these policies.