This Employer Requires a Pre-Employment Physical and Drug Test

APPLICATION

We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation or any other legal protected status.

This employer requires a pre-employment physical and drug test.

Position(s) applied for: Date of Application:

Last Name: First Name: Middle Initial:

Have you ever been known by another name or by an alias? Yes No If yes, what?______

Present Address: City: State: Zip: ______

Permanent Address: City: State: Zip:______

Home Phone: Cell/Pager Phone:

Social Security #: Citizen of US? __

Drivers License Number:______License Class:______

APPLICATION FOR EMPLOYMENT

, INC.

Notice: Valley Paving, Inc./River City Asphalt requires that applicants to present themselves in person to sign our application at our office the signature page (or specified project or job site hiring office) the Employer’s original employment application form and will not accept third-party applications or unsolicited employment referrals from any source.

Valley Paving, Inc./River City Asphalt is an equal employment opportunity employer and will not discriminate against any applicant or employee on any grounds protected under federal, state, or local statute, ordinance or regulation, including race, color, creed, religion, age, sex, sexual orientation, national origin, ancestry, martial status, pregnancy, disability (including those related to pregnancy or childbirth), status with regard to public assistance, membership or non-membership in a labor organization, military, National Guard or reserve service, complaining in good faith to the Employer or to a public authority, or any other characteristic protected under federal, state or local statute, ordinance or regulation. None of the questions in this application are intended to elicit information regarding any protected characteristics, nor imply any limitation, illegal preferences or discrimination based upon non-job-related information or protected characteristics.

If hired, can you furnish proof that you are 18 years of age or older? Yes No

If no, explain______

If hired, can you furnish proof that you are eligible to work in the United States? Yes No

If no, explain______

Have you applied to work at our Company before? Yes No

If yes, when, what position, and reason for leaving______

Are you available to work at any time of the day or week as needed? Yes No

If not, please explain limitations______

May we contact your present employer? Yes No

Have you ever been convicted of a crime? (minor traffic violations may be omitted) Yes No If yes, provide the date,

location, circumstances, and identify the offense(s) and jurisdiction (s)______

Date you can start ______

Are you available for work: Full time Part time Temporary

Are you currently on “lay-off” status and subject to recall? Yes No

Can you travel if a job requires it? Yes No

Have you served in the Military? Yes No

If yes, which Branch and rank, and nature of discharge______

Briefly describe any military duties related to position-applied for______

Present Membership in National Guard or Reserves?______

Have you ever worked in a position similar to the one for which you are applying? ______

List of tools or equipment for which you have experience , which might be helpful on this job, or if you hold a state journeyman or any relating public or private licenses, certificates or competency cards, please provide details, including issuing authority and any license or other numbers______

Where have you gained this experience______

If you will be driving company vehicles, please answer these questions:

Do you have a current, valid and unrestricted driver’s license (s)? Yes No If yes, what class of license (s) and which state(s):______

Have you received DWI, DUI or other driving violations within the past two years? Yes No If yes, please explain:______

Valley Paving, Inc./River City Asphalt requires that each employee purchase a specified set of tools as a condition of employment. Each individual employee is responsible for having access to these tools each day, and the employee is responsible for transporting his/her own tools to each project or job site. Are you willing to purchase such tools and do you have a valid driver’s license and access to a vehicle sufficient to transport tools to and between job sites on a daily basis?

Yes No If yes, please explain______

Do you plan to work for any other employer or engage in self-employment during your period of employment with Valley Paving, Inc./River City Asphalt?

Yes No If yes, please explain______

Are there any employer policies, requirements or terms or conditions of employment, which you are unwilling to accept if you are offered employment?

Yes No If yes, please explain______

You may be asked to provide a medical history, submit a drug and/or alcohol test and/or physical examination if you are made a conditional offer of employment. Are you will to do so? Yes No

EDUCATION

Name/Address of School / Course of Study / Number of Years / Degree
Elementary
School
High School
Undergraduate College
Graduate
College
Other (Specify)

Describe any specialized training, apprenticeships, skills or extra-curricular activities:

Describe any hobbies or activities that you enjoy doing:

Employment Experience

Begin with your present or last job. Please include any job- related military service assignments and volunteer activities.

Employer: / Dates Employed: / Work Performed:
Address: / From:
Phone Number: / To:
Job Title: / Hourly Rate:
Reason for Leaving: / Start: End:

Additional Information

Summarize special job-related skills and qualifications acquired from past employment or experience plus any additional information you feel may be helpful to us in considering your application:

Specialized Skills

Check Skills/Equipment Operated:

Operators / Laborers / Drivers
Paver / Gravel / Belly
Superintendent / Roller
Dozer / Bit / Tri-Axle
Foreman / Blade
Loader / Raker / Tandems
Mechanic / Skid
Broom / Jackhammer / Distributor
Truck / Mill
Dispatcher / Excavator / Manhole / Transport

References

Give the names of three persons NOT related to you, whom you have worked with at least one year:
1.
(Name) (Phone Number)
(Address)
2.
(Name) (Phone Number)
(Address)
3.
(Name) (Phone Number)
(Address)

Acknowledgment Please Read and Sign (if you agree):

By my signature below, I promise that the information provided in this employment application (and any related information provided by me) is true and complete, and I understand that any false or misleading information or significant omission may disqualify me from further consideration for employment, and may lead to my dismissal from employment, if discovered at a later date, no matter how long I have been employed. I agree to immediately notify Valley Paving, Inc./River City Asphalt.

I authorize Valley Paving, Inc.,/River City Asphalt, Inc. (the “Employer”) to obtain and/or to provide any and all information an opinion, which the Employer elects to obtain, use or provide in connection with my application for employment and/or employment with the Employer, prior to, during and after my employment. Such information and opinion may be south from any and all prior employers (except as noted above, schools or other persons or organizations who may have information the Employer deems relevant in connection with my application for employment and during my employment, and may be provided by the Employer in response to any request for information opinion concerning my employment or my separation from employment with the Employer, to any and all banks or mortgage companies, government agencies, insurers, prospective employers or other schools, person or organizations deemed appropriate for receipt of such information by the Employer. I understand the Employer may provide any and all information and opinion, which may include, but are not limited to opinions about my conduct, performance, attendance, or any other aspect of my reputation or character, which may be positive or negative. I agree to hold the Employer (including its principals, employees, agents, consultants, attorneys and insurers) and such other employer, school, person or organization providing or receiving any such information and opinion, harmless and free of any and all claims or causes of action arising from any such provision or receipt of information an opinion, no mater what is the character.

I understand that this application does not create a contract of employment. I understand that, if hired I am obligated to comply with any and all current and subsequently adopted Valley Paving, Inc./River City Asphalt policies and that Valley Paving, Inc./River City Asphalt does not offer contracts, promises or representation related to employment. I understand and agree that, if hired my employment is for no definite period or time and may, regardless of the date of payment of wages or salary, be terminated at any time for any reason, with or without cause, notices or prior warning or discipline. I understand that no person is authorized to change any of the terms mentioned in this employment application.

______

Signature of Applicant Date

HIRING POLICY

It is the policy of Valley Paving, Inc./River City Asphalt to accept applications for employment from individuals directly, or through a job service office of our choosing or that is a representative of our company. Valley Paving/River City Asphalt will not accept applications that have been completed and signed by anyone other than the individual applying for the position.

It is the policy of Valley Paving Inc./River City Asphalt to provide equal employment opportunity to all individuals and not discriminate on the basis of race, color, religion, sex, national origin, age, alliance, marital or familial status or any other classification which is protected by law. It is the intent of Valley Paving to be in compliance with all federal and local laws with regards to its hiring policy.

No job site applications or hiring shall be permitted. This would cause safety hazards and unauthorized personal on the job site.

Valley Paving Inc./River City Asphalt will hire employees only when its needs and circumstances dictate. Any applicant must complete an application provided by the company. Valley Paving/River City Asphalt will not accept applications on forms other than which our company provides.

If Valley Paving Inc./River City Asphalt receives an application for employment during a time period when we are not hiring, we will maintain that application on file for 30 days from the date of the application. Such filings do not guarantee that an application will be considered at a future date. This is done not to discriminate against any person or individual, but it is merely a reflection of the needs and circumstance, which may dictate the company’s action at that time.

Valley Paving, Inc./River City Asphalt reserves the right to evaluate all applicant’s physical fitness for positions based on relevant criteria, including minimum or maximum experience and education, appropriate wage or salary history for the position sought, willingness to perform all duties assigned, skill levels, attitudes, demeanor, and all other criteria deemed relevant by Valley Paving’s sole discretion.

Valley Paving Inc./River City Asphalt reserves the right to assess prior work experience and skill levels, and confirm applicants work references, driver’s license for positions requiring driving, and education and licensure where applicable, and will require applicants to authorize and hold Valley Paving harmless with respect to any such inquiries of former employers.

Valley Paving, Inc./River City Asphalt requires that applicants and employees provide truthful responses to all employment-related inquiries, both written and verbal, and reserves the right to reject any applicant and terminate any employee for providing false or misleading employment-related information, or omitting relevant information, no matter when these violations are discovered. Failure to provide complete and accurate responses to all questions, without material omission, will disqualify applicants from consideration for employment with Valley Paving, Inc./River City Asphalt.

Signed Date