Please complete the following information:

Job Location
Position Applied For
Sometimes a job may require that we work at night, to avoid
heavy traffic, thus creating a safer work environment for our
employees.
Can you work nights?

YesNo

Can you work weekends?
YesNo

Are you willing to work overtime?
YesNo

Are you willing to travel out of town with overnight stays?
YesNo

How did you learn about us?
AdvertisementEmployment agencyFriendRelativeWalk InOther

Employment Desired
Full TimePart TimeFull or Part Time

When are you available to start work?

Do you speak or write any foreign languages?
YesNo

If so, what language(s)?

Are you a citizen of the United States?
YesNo

If no, are you authorized to work in the U.S.?
YesNo

Have you ever worked for this company?
YesNo

If so, when?

Have you ever been convicted of a felony?
YesNo

If yes, explain.

Have you ever had an adjudication withheld, or nolo contendere?
YesNo

If yes, explain.

EDUCATION

High school

Address

From

To

Did you graduate?
YesNo

Diploma?
YesNoGED

College

Address

Attended college from

Attended college until

Did you graduate?
YesNo

Degree

Business or Trade School

Address

Business or trade school attended from

Business or trade school attended until

Did you graduate?
YesNo

Degree

Do you have a driver's license?
YesNo

Do you have reliable transportation to work?
YesNo

Driver's license number

State of Issue

Expiration Date

Type
OperatorCommercial (CDL)Chauffeur

Have you had any accidents during the past three years?
YesNo

How many?

Have you had any moving violations during the past three years?
YesNo

How many?

REFERENCES

Please list three professional references.

#1 Full Name

Relationship

Company

Phone

Address

#2 Full Name

Relationship

Company

Phone

Address

#3 Full Name

Relationship

Company

Phone

Address

An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying.

PREVIOUS EMPLOYMENT

Company #1

Phone

Address

Job Title

Supervisor

Starting Pay Rate

Ending Pay Rate

From

To

Reason for Leaving

May we contact your previous supervisor for a reference?
YesNo

List the responsibilities, duties performed, skills used or learned, advancements or promotions while you worked at the company.

Company #2

Phone

Address

Job Title

Supervisor

Starting Pay Rate

Ending Pay Rate

From

To

Reason for Leaving

May we contact your previous supervisor for a reference?
YesNo

List the responsibilities, duties performed, skills used or learned, advancements or promotions while you worked at the company.

Company #3

Phone

Address

Job Title

Supervisor

Starting Pay Rate

Ending Pay Rate

From

To

Reason for Leaving

May we contact your previous supervisor for a reference?
YesNo

List the responsibilities, duties performed, skills used or learned, advancements or promotions while you worked at the company.

PLEASE READ CAREFULLY

APPLICATION FORM WAIVER

In exchange for the consideration of my job application by C.W. Roberts Contracting, Inc. (hereinafter called “the Company”), I agree that:
Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any
other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may
exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to
remain an employee of C.W. Roberts Contracting, Inc., or otherwise to change in any respect the employment-at- will relationship between it and the
undersigned, and that relationship cannot be altered except by a written instrument signed by the President/General Manager of the Company. Both
the undersigned and C.W. Roberts Contracting, Inc. may end the employment relationship at any time, without specified notice or reason. If
employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include a
reduction in benefits.

I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is
cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless
otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contract.
I also understand that (1) the Company has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment;
(2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing
of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical
examinations.

I certify that I have received a written notification that the Company may obtain a consumer report or reports on me. I authorize this Company to
obtain such a report or reports for use in connection with my application for employment and for other employment-related reasons. If hired, this
authorization shall remain on file and serve as ongoing authorization for procurement of employment-related consumer reports at any time during my
employment. I understand that the term “consumer report” includes, but is not limited to, credit checks, criminal background checks, Department of
Motor Vehicle reports, and investigative consumer reports. I authorize the Company to conduct electronic inquiry related to my background,
including review of all social networking sites and to make adverse decisions as a result of such inquiries. I further understand that the term
“investigative consumer report” means a report in which information on my character, general reputation, personal characteristics, or mode of living
is obtained through personal interviews with my neighbors, friends, or associates, or with others with whom I am acquainted or who may have
knowledge concerning any such items of information.

I further understand that my employment with the Company shall be probationary for a period of (90) days, and further that at any time during the
probationary period or thereafter, my employment relation with the Company is terminable at will for any reason by either party.
This Company provides equal employment opportunities to all employees and applicants without regard to race, color, religion, sex,
sexual orientation, national origin, citizenship, age, pregnancy, disability, or any other protected status. We assure of my job application by C.W. Roberts Contracting, Inc. (hereinafter called “the Company”), I agree that:

Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any
other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may
exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to
remain an employee of C.W. Roberts Contracting, Inc., or otherwise to change in any respect the employment-at- will relationship between it and the
undersigned, and that relationship cannot be altered except by a written instrument signed by the President/General Manager of the Company. Both
the undersigned and C.W. Roberts Contracting, Inc. may end the employment relationship at any time, without specified notice or reason. If
employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include a
reduction in benefits.

Acknowledgment and Agreement:

EEO SURVEY

We consider applicants for all positions without regard to race, color, sex, national origin, religion, age, marital status, genetic information status, pregnancy, disability, veteran status, sexual orientation, gender identification, transgender, or any other legally protected class. The information requested on this form is collected by the company to comply with Affirmative Action/Equal Employment Opportunity and other federal laws and regulations. This information is considered confidential and will not be a part of your official application for employment.

Position title for which you are applying:

Gender:
MaleFemale

Date of Birth:

Race:
Hispanic or LatinoWhite (Not Hispanic or Latino)Black or African American Native Hawaiian or Other Pacific IslanderAmerican Indian or Alaska NativeAsianTwo or More Races

You are invited to identify yourself as a disabled veteran, veteran of the Vietnam Era, or disabled individual. This information is voluntary and will be kept confidential. Refusal to provide it will not subject you to any adverse treatment. The information will be used for affirmative action purposes. It is not used or considered in the selection process and is filed separately from the application.

The Vietnam Era is defined by Federal Regulations as August 5, 1964 to May 7, 1975.

Veteran Status: Which applies to you?

Disabled Veteran: A Veteran entitled to compensation for disability rated at 30% or more, or a person who is discharged or released from active duty because of a service connected disability.Recently Separated Veteran: A Veteran who served on active duty in the U.S. military, ground, naval or air service during the three-year period beginning on the date of such veteran’s discharge or release from active duty.Active Duty Wartime or Campaign Badge Veteran: 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 by the Department of Defense.Armed Forces Service Medal Veteran: A 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.I am a protected veteran, but I choose not to self identify the classifications to which I belong.I am not a protected veteran.

To qualify as a Disabled Individual, you must:
1. Have a physical or mental impairment which substantially limits one or more life activities (including employment);
2. Have a record of such impairment; or
3. Be regarded as having such impairment.

Do you qualify as such an individual?

YesNo

This information is for compliance reporting only.
It will be removed from your application prior to review.
It is not considered in the employment process.