APPLICATION FOR EMPLOYMENT

PERSONAL INFORMATION

PRESENT ADDRESS

PERMANENT ADDRESS

EMPLOYMENT DESIRED

* THE AGE DISCRIMINATION IN EMPLOYMENT ACT OF 1967 PROHIBITS DISCRIMINATION ON THE BASIS OF AGE WITH RESPECT TO INDIVIDUALS WHO ARE 40 YEARS OF AGE OR OLDER

EDUCATION

ELEMENTARY SCHOOL

HIGH SCHOOL

COLLEGE

TRADE BUSINESS OR CORRESPONDENCE SCHOOL

FORMER EMPLOYERS

DATE MONTH AND YEAR

DATE MONTH AND YEAR

DATE MONTH AND YEAR

DATE MONTH AND YEAR

REFERENCES: GIVE BELOW THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR

IN CASE OF EMERGENCY NOTIFY

I AUTHORIZED INVESTIGATION OF ALL STATEMENTS CONTAINED IN THIS APPLICATION, I UNDERSTAND THAT MISREPRESENTATION OR OMISSION OF FACTS CALLED FOR IS CAUSE FOR DISMISSAL, FURTHER, I UNDERSTAND AND AGREE THAT MY EMPLOYMENT IS FOR NOT DEFINITE PERIOD AND MAY, REGARDLESS OF THE DATE OF PAYMENT IF MY WAGES AND SALARY, BE TERMINATED AT ANYTIME WITHOUT ANY PREVIOUS NOTICE

DO NOT WRITE BELOW THIS LINE

HIRED

IF YES,

CONSENT FORM

I understand, as required by the C & I Roofing Company, Inc. Company policy and/or Department of Transportation regulations, all employees are required to submit to a drug test. A urine speciment will be collected at collection site selected by the company and tested for drugs at a DHHS-certified laboratory selected by Company. The laboratory results will be reported,  reviewed and maintained by the Medical Review Officer (MRO) selected by Company, who will report whether the test was negative or positive (and if positive, which drugs(s) where detected) to myself and to Company. I will be given an opportunity to explain a positive test result to the MRO before the test result is reported to Company as verified positive. Test results will not be released to any addtional parties without my written authorization.

I hereby agree to voluntary submit to a drug and/or alcohol test and further understand if said test is verified as a positive by the MRO Company policy will be followed to which could include termination.

IF YOU HAVE ANY QUESTIONS, PLEASE DISCUSS WITH THE COMPANY BEFORE SIGNING

COMPANY: COMMERCIAL & INDUSTRIAL ROOFING COMPANY, INC.

LOCATION ADDRESS: 9239 OLIVE DRIVE