Application for Employment

To the Applicant: We appreciate your interest in our company and assure you that we are interested in your application. A clear understanding of your background and work history will aid us in seeking to place you in a position that, in our judgement, best meets your qualifications.

We are an equal opportunity employer and will not unlawfully discriminate on the basis of race, color, sex, religion, national origin, age, marital or veteran status, the presence of a medical condition or handicap, height, weight or any other protected status.

Personal

First name

Last name

Date

Month

Day

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Social Security Number

Are you 18 years or older?

Yes

Are you a U.S. Citizen?

Yes

*Not Applicable in California

Are you authorized to work in the United States?

Yes

Have you been previously employed here?

Yes

If yes, date(s):

Supervisors Name(s)

Have you filled out an application before?

Yes

If yes, Date(s)

List any friends or relatives working here

What method of transportation will you use to come to work?

Employment Desired

Position(s) applied for

Kind of work sought?

Full Time

Part Time

Other

Do you have any special training, skills, qualifications, or other experiences related to the position(s) you applied for?

Salary Desired

Date available to work

Employers must make accommodations to disabled applications and employees where the accommodation does not impose an undue hardship on the employer.

Under Michigan law only, disabled employees and applicants may request an accommodation of their disability by notifying the firm in writing of the need for accommodation within 182 days of the date the disabled individual knows or should know that an accommodation is needed. This requirement does not apply to an individual's right under the Americans with Disabilities Act. Failure to properly notify the firm may preclude any claim that the employer failed to accommodate the disabled individual. Rohde Bros. Excavating, Inc. 1240 N. Outer Dr. Saginaw MI 48601 "An Equal Opportunity Employer"

Employment Experience

List current or most recent job first

1. Company name

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Date of employment

Job title

Hourly rate/salary

Supervisor

Reason for leaving

Work Performed

2. Company name

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Date of employment

Job title

Hourly rate/salary

Supervisor

Reason for leaving

Work performed

List any other positions held below.

Education

High School name and location

Years completed

Diploma/Degree

Courses of study

College name and location

Years completed

Degree

Courses of Study

Graduate School name and location

Years completed

Degree

Courses of study

Vocational/Training name and location

Years completed

Diploma/Degree

Courses of study

Any other educational training?

References

Do not include relatives or former employers

1. Name

Address

Phone

Years acquainted

2. Name

Address

Phone

Years acquainted

3. Name

Address

Phone

Years acquainted

Military Service Record

Do you have experience in the Armed Forces of the United States or in a State National Guard?

Yes

If yes, what branch?

Rank at Discharge

Date of Discharge

Are you in the Reserves?

Yes

If yes, date of obligation ends

Special/technical training

Additional Information

Have you ever been convicted of a crime?

Yes

If yes, where, when, and nature of the offense

Do you have a valid Driver's License?

Yes

License Number and issuing State

List professional trade, business or civic activities and offices held excluding groups the name or character of which indicate race, color, religion, sex, national origin, handicap, marital or veteran status, height, weight, or age

State any additional information that you may feel helpful to us in considering your application

Name, address, and telephone number of person to be notified in the event of accident or emergency

Authorization and Understanding

Upon the signing of this application, I represent that all of the information now or hereafter given by me in support of my application is true and complete. I authorize you to verify any of the information concerning my employment, education, criminal history, or medical history (post-offer only), with the appropriate individuals, companies, institutions, or agencies, and I authorize them to release such information as you require, including my prior disciplinary employment record, without any obligation to give me written notice of such disclosure. I also authorize you to release any information requested by any of my prospective or subsequent employers without any obligation to give me written notice of such disclosure. I hereby release you and them from any liability whatsoever as a result of any such inquiries and disclosures and this release from liability does not waive or prohibit an individual from filing a charge of discrimination under the laws enforced by the EEOC. I agree that any false information in support of my application may subject me to discharge at any any time during the period of my employment. I agree that either party may terminate the employment relationship, with or without cause, at any time, and I further agree that this arrangement may only be altered in writing directed to me personally and signed by the president of the firm. I agree that I shall be bound by the other rules, policies, regulations and terms and conditions of employment of the firm as they are from time to time changed, and no additional obligations can be imposed on the firm except those which have been acknowledged in writing, by the president or his designated representatives. I herby authorize the firm to deduct from each and every period of my pay amounts necessary to offset any damages caused by me or the value of property or money entrusted to me by or owed by me to the firm during the course of my employment. I agree that any action or suit against the firm, its agents or employees, arising out if my employment or termination of employment, including, but not limited to, claims arising under State, but not Federal, civil rights statues, must be brought within 180 days of the event giving rise to the claims or be forever barred. I waive any limitation periods to the contrary. I further agree that if I should bring any non-statutory action or claim arising out of my employment against the firm, in which the firm prevails, I will pay to the firm any and all such costs incurred by the firm in defense of said claims or actions, including attorney fees. I further agree that my employment is conditional until such time as the results of my post-offer physical (if physical is required) are known.

Signature

Signature field is empty.

Full Name

Date

Month

Day

Year

Affirmative Action Program Questionnaire

This Company is in full compliance with federal, state, and local laws and with Executive Order 11246, as amended, is committed to the continual evaluation of our Affirmative Action Program (AAP).

To evaluate our progress as an Equal Opportunity Employer, we are asking applicants to complete this questionnaire.

INFORMATION PERTAINING TO SEX AND RACE/ETHNIC HERITAGE IS REQUIRED. INFORMATION PERTAINING TO VETERAN AND DISABILITY IS VOLUNTARY AND WILL NOT SUBJECT YOU TO ANY ADVERSE TREATMENT.

Confidential Applicant Information

Sex

Male

Female

Race/Ethnic Heritage (Please check one). If two or more categories apply, choose the one with which you most closely identify

American Indian or Alaska Native - Persons having origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition

Asian Indian or Pacific Islander - Persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands

Black, not of Hispanic origin - Persons having origins in any of the black racial groups of Africa

Hispanic - Persons of Mexico, Puerto Rican, Cuban, Central or South American, or the Spanish culture of origin, regardless of race.

White - not of Hispanic origin - Persons having origins in any of the original peoples of Europe, North Africa, or the Middle East

Other

Veterans

Are you a Disabled Veteran - Must be entitled to disability by the Veterans Administration, rated at least 30% disabled; or discharged or released from active duty for a disability incurred or aggravated in the line of duty

Yes

If yes, please indicate limitations to be considered in job placement

Are you a Vietnam Era Veteran - A person who both served on active duty for more than 180 days between August 5, 1965 and May 7, 1975, AND whose application for employment is submitted with 48 months of discharge or release

Yes

If yes, please indicate limitations to be considered in job placement

Disabled - A person who has a physical or mental impairment which substantially limits one or more life activities, has a record of such an impairment, or is regarded as having such an impairment

Yes

If yes, please indicate limitations to be considered in job placement

Signature

Signature field is empty.

Full Name

Date

Month

Day

Year

Been There, Dug That, Still Digging

1240 N. Outer Dr. Saginaw, MI 48601

Application for Employment

Personal

Employment Desired

Employment Experience

Education

References

Military Service Record

Additional Information

Authorization and Understanding

Affirmative Action Program Questionnaire

Veterans