National Broadband Application

National Broadband Application

Name*FirstMiddleLast

Date of Birth*

Address* Street Address City* State

Zip Code

Home Phone*

Cell Phone*

Driver's License*

Driver's License State*

Height

Weight

Hair Color

Eye Color

Aliases

Prior addresses for the past 7 years

Vehicle Information

Make*

Model*

Year

Color

Tag #

Vehicle Tag State

Vehicle Insurance

Policy Number

Issuing Authority

Expiration

With the vehicle that you intend to use for work are you listed under the policy as a driver?*

Is the registration listed under your name for the vehicle that you intend to use for work?*

If the registration is not under your name are you able to get a letter of permission that will allow you to use the vehicle for work purposes from whom the vehicle is registered to?

Years of cable/broadband experience*

If experienced, how many NCTI or SCTE tests have you passed?

Position Applying for: *

Referred by:

How did you hear about us?*

Where are you submitting your information from? *

References

Name

Phone

Name

Phone

Name

Phone

Which branch do you want to submit your information to? *

Do you have a truck or van capable of carrying a 28ft ladder?

Are you fit and able to work outdoors in a variety of weather conditions?

Are you comfortable working at heights in excess of 15ft?

Have you ever been convicted of, or pleaded no contest or nolo contendre to a crime?

If Yes, explain the circumstances