Northern Concrete Construction Inc.

Employment
Application

 We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, sex, religion or national origin.

Personal Information
Name First
 Last
 Middle
Present
Address		 Street
 City
 State
 Zip
Home Phone ()- Work Phone ()-

Employment Desired
Please check all positions you are appling for:
Flatwork Crew | Wall Crew | Office
Specific postition title (If applicable)
 Date you can start
 Salary desired
Available:
Full Time | Part Time (specify days and times)
Have you worked for Northern Concrete before?
Yes / No 		If yes, in what capacity?
Have you ever been discharged by a previous employer?
Yes / No 		Reason

Education
High School Name and Location of School
 Last Year
Completed
 Did You Graduate or complete a GED?
Yes / No 		Subjects Studied or Degree(s) Earned
College Name and Location of School
 Last Year
Completed
 Did You Graduate?
Yes / No 		Subjects Studied or Degree(s) Earned
Trade, Business, Technical Name and Location of School
 Last Year
Completed
 Did You Graduate?
Yes / No 		Subjects Studied or Degree(s) Earned

EXPLAIN ANY ADDITIONAL EXPERIENCE, TALENTS, OR SKILLS THAT YOU POSSESS WHICH WOULD BE APPLICABLE TO THE POSITION FOR WHICH YOU ARE APPLYING:

Employment History

CURRENT EMPLOYER:
Street / City / State / Zip:
DATE
From mm/yyyy
 To mm/yyyy
Position held and title
Salary/Wage
Reason for leaving
Duties
Phone Number:

Supervisors name & phone number:
PAST EMPLOYER 1:
Street / City / State / Zip:
DATE
From mm/yyyy
 To mm/yyyy
Position held
Salary/Wage
Reason for leaving
Duties
Phone Number:

Supervisors name & phone number:
PAST EMPLOYER 2:
Street / City / State / Zip:
DATE
From mm/yyyy
 To mm/yyyy
Position held
Salary/Wage
Reason for leaving
Duties
Phone Number:

Supervisors name & phone number:
PAST EMPLOYER 3:
Street / City / State / Zip:
DATE
From mm/yyyy
 To mm/yyyy
Position held
Salary/Wage
Reason for leaving
Duties
Phone Number:

Supervisors name & phone number:
PAST EMPLOYER 4:
Street / City / State / Zip:
DATE
From mm/yyyy
 To mm/yyyy
Position held
Salary/Wage
Reason for leaving
Duties
Phone Number:

Supervisors name & phone number:

Have you ever been convicted of any violations of law - felonies, misdemeanors, and/or ordinance violations other than minor traffic violations?  (In accordance with state law, convictions will not be used or considered in making an employment decision unless the circumstances of the charge or conviction are substantially related to circumstances of the particular job.)  Yes / No

Do you presently have any pending violations of law: felonies, misdemeanors, and/or ordinance violations other than minor traffic violations?  (In accordance with state law, pending charges will not be used or considered in making an employment decision unless the circumstances of the charge or conviction are substantially related to circumstances of the particular job.)  Yes / No

"Conviction record" includes, but is not limited to, information indicating that an individual has been convicted of any felony, misdemeanor, or other offense, has been less than honorably discharged, or has been placed on probation, fined, imprisoned or paroled pursuant to any law enforcement or military authority regardless of whether an appeal is pending or could be taken.

 Please be aware that a ticket/citation may constitute an arrest or conviction.  Keep in mind that participation in a deferred prosecution program (such as First Offenders) does not necessarily mean your record is clear.  If you are unsure about your record, you should contact your state or local law enforcement agency prior to completing this form. Failure to complete this form accurately and completely may mean disqualification from consideration for employment or may be cause for dismissal if employed.

If you answered “Yes, ” to any of the above, complete the following:
Charge:
 Date and court of conviction:
County and state:
 Ammount of fine:
 Length of jail term:
Charge:
 Date and court of conviction:
County and state:
 Ammount of fine:
 Length of jail term:

IMPORTANT - MUST BE COMPLETED WITH YOUR SIGNATURE

I certify that the answers given by me to the foregoing questions and/or statements are complete, true, and correct to the best of my knowledge and without misrepresentation or omissions of any kind.  I further understand that the making of any false or misleading statement or willful omission from or on this Employment Application, or any other document, may be used to deny me employment, or if employed, used for discipline, including termination from employment.  I understand that the Northern Concrete shall not be held liable in any respect if my employment is terminated because of false or incomplete statements, answers or omissions made by me on this Employment Application or any other document.  I authorize Northern Concrete to make any investigation of my employment history and any other information related to my suitability for employment and authorize any employment reference(s) to disclose to Northern Concrete any such information about me they may have.  In consideration of our review of this application, I hereby release Northern Concrete as well as all providers of information, from any liability and for any damage which may result from the furnishing and receiving of this information.  A copy of this authorization and release is valid as the original and should be recognized as such.

SIGN YOUR NAME HERE.  Your signature affirms that all the information on this application is true to the best of your knowledge.  Only complete applications will be considered.  Applications will be retained for one year only from the date the application is received by Human Resources.
Date / Full Name
This is a valid electronic signature and you agree all of the information you have supplied is valid.

With respect to employment and personnel operations, Northern Concrete Construction, Inc. does not discriminate on the basis or religion, race, creed, color, national origin, ancestry, age, sex, marital status, disability, arrest or conviction record, membership in the National Guard, state defense force, or any reserve component of the military forces of the United States or this state, or less than honorable discharge.
®2007 Northern Concrete
Construction Inc.