Application for Employment

Equal Opportunity Employer

Taylor Construction Inc.
7314 Columbus St.
P.O. Box 110
New Vienna, IA 52065

Phone: (563) 921-2315
Fax: (563) 921-3845

Applications are considered active for 60 days from the date of signature. After 60 days, reapplication is necessary.

If you become an employee of this Company, you will be expected, by Company Safety Policies, to wear the authorized personal safety equipent, when warranted, such as hard hat, sfety glasses, hearing protection, etc. Failure to follow the Company Safety Policies will result in disciplinary action up to and including termination.

NOTE: None of the information requested will be used to discriminate against any individual for any reason prohibited by law.

Please answer all questions If question does not apply, mark "n/a".

PERSONAL

Position Desired:*

How did you learn about this position?

First Name:*

Last Name:*

Middle Initial:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone

Mobile Phone

Email*

Social Security#:

Have you ever used a name other than that shown above? (Nick-name also)

Yes

If so, list name and dates used:

Have you ever used another social security number?

Yes

If so, list number and dates used:

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? (Proof of citizenship or immigration will be required prior to beginning employment)

Yes

Are you available to work?

Full-Time

Part-Time

Temporary

Are you currently employed?

Yes

May we contact your present employer?

Yes

Are you currently on "lay-off" status and subject to recall?

Yes

Have you ever been employed by us before?

Yes

If Yes, give date:

Can you travel if the job requires it?

Yes

Out of town?

Yes

Out of State?

Yes

Do you have reliable transportation to get yourself to and from the job site?

Yes

Have you ever been convicted of any crime?

Yes

(Conviction will not necessarily disquality an applicant from employment)

If Yes, explain:

State any reason why you will, if hired, be unavailable for work for a period of time exceeding one week in the year.

EMPLOYMENT

Instructions to applicant:

List employment for at least 10 years. All time must be accounted for (explain any gaps in employment).
If former employer out of business, furnish name & phone number or address of person who can verify your employment
If self-employed, furnish name, phone number or addresss of a non-relative who can verify employment.

Is your present employer aware that you are seeking other employment?

Yes

Employment Record
(Start with your most recent employment)

Company Name #1:

Employer #1 Address:

Supervisor #1 Name:

Employer #1 Phone:

Starting #1 Salary:

Ending #1 Salary:

Start Date #1 (Mo/Yr):

End Date #1 (Mo/Yr):

Reason For Leaving #1:

Positions held and duties performed #1:

Company Name #2:

Employer #2 Address:

Supervisor #2 Name:

Employer #2 Phone:

Starting #2 Salary:

Ending #2 Salary:

Start Date #2 (Mo/Yr):

End Date #2 (Mo/Yr):

Reason For Leaving #2:

Positions held and duties performed #2:

Company Name #3:

Employer #3 Address:

Supervisor #3 Name:

Employer #3 Phone:

Starting #3 Salary:

Ending #3 Salary:

Start Date #3 (Mo/Yr):

End Date #3 (Mo/Yr):

Reason For Leaving #3:

Positions held and duties performed #3:

Company Name #4:

Employer #4 Address:

Supervisor #4 Name:

Employer #4 Phone:

Starting #4 Salary:

Ending #4 Salary:

Start Date #4 (Mo/Yr):

End Date #4 (Mo/Yr):

Reason For Leaving #4:

Positions held and duties performed #4:

Company Name #5:

Employer #5 Address:

Supervisor #5 Name:

Employer #5 Phone:

Starting #5 Salary:

Ending #5 Salary:

Start Date #5 (Mo/Yr):

End Date #5 (Mo/Yr):

Reason For Leaving #5:

Positions held and duties performed #5:

EDUCATION

H.S. Name/Location:

H.S. Dates:

H.S. Graduated?

H.S. Major/Minor/Hrs:

College Name/Location:

College Dates:

College Graduated?

College Major/Minor/Hrs:

Tech Name/Location:

Tech Dates:

Tech Graduated?

Tech Major/Minor/Hrs:

REFERENCES

Name #1:

Address #1:

Phone #1:

Association #1:

Name #2:

Address #2:

Phone #2:

Association #2:

Name #3:

Address #3:

Phone #3:

Association #3:

POST-OFFER PHYSICAL/TESTING NOTICE

Taylor Construction, Inc. is committed to maintaining a drug-free workplace. Therefore, all candidates for employment (applicants to whom a contingent offer of employment has been made) are required to complete a medical examination, including a testing for drug/alcohol use, by a physician of Taylor Construction, Inc.'s choice. An offer of employment is contingent upon a candidate's submission to and successful completion of the medical exam and test.

EMPLOYMENT ELIGIBILITY VERIFICATION

Pursuant to the Immigration Reform and Control Act of 1986, all applicants upon being made an offer of employment, must produce documents, wherein are specified by the federal government, establishing your identity and authorization for employment in the United States. These documents must be produced no later than 3 days after commencement of employment. You will also be required to sign the Form I-9 9issued by the federal government) verifying, under oath, your employment authorization.

APPLICANT ACKNOWLEDGEMENT

In the event that a job offer is extended to me, I agree to undergo a post-offer physical and drug/alcohol test. I understand that the results of such a test will be disclosed only to Taylor Construction, Inc.'s Human Resource personnel and other with a need to know, or as required by law. I understand that if I refuse to consent to testing, fail to provide a urine sample when requested, provide a false or tampered urine sample, or fail to successfully complete the physical or drug/alcohol test, I will not be hired in accordance with Taylor Construction, Inc.'s policy.

Permission is granted to Taylor Construction, Inc. to conduct an investigation and to solicit information as to my education, employment history, character and general reputation, driving record and criminal record. I release Taylor Construction, Inc. and all persons and organizations from any liability arising from such statements, their solicitation or use.

I understand that federal law prohibits the employment of unauthorized alien; all persons hired must submit satisfactory proof of employment authorization and identity; failure to submit proof will result in denial of employment.

I understand that this employment application and other company documents are not contracts or employment and that any individual who is hired may voluntarily leave or be terminated at any time, with or without cause. If terminated, I authorize Taylor Construction, Inc. to deduct, to the extent permitted by law, any amount I may owe to Taylor Construction, Inc. from any amount that Taylor Construction, Inc. may owe me. I understand that no representative of Taylor Construction, Inc. has any authority to offer or to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing.

I certify that all statements made by me on this application are true, complete and correct. I understand that any false, misleading, inaccurate, or omitted facts could result in the rejection of my application or termination of my employment at any time. I have read, understand, and by my signature consent to all disclosures and statements.

By inputting my name below, I am electronically signing this form.

Heavy-highway contractor based in Iowa