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List professional, trade, business or civic activities and offices held. You may exclude memberships which would reveal sex/gender, race, religion, national origin, age, ancestry, disability or other protected status.

Summarize special job-related skills, qualifications, licenses or certifications acquired from employment or other experiences that you believe may be helpful to us in considering your application.

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Provide the following information, starting with your present or most recent job, and include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, sex/gender, national origin, ancestry, disability or other protected status.

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Give names, addresses and telephone numbers of three references that are not related to you.

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DRUG TEST AND PHYSICAL – In applying for employment, I understand that I have agreed to undergo a urine screening test to determine the presence of certain drugs. I further understand that the presence of one or more of those drugs may cause my rejection from further consideration for employment. If I am offered a job, I also understand that I have agreed to undergo a physical to dete rmine if I am physically able to perform the required job duties. I further understand that failure of the physi cal may cause my rejection from further consideration for employment.

I hereby authorize the Henry Carlson Company/Asphalt Surfacing Company to conduct through its designated physician or laboratory testing facility a drug screening test and a physical as a requirement of employment.

I also understand that refusal to submit to the drug screeni ng test and physical will constitute voluntary withdrawal of my application for employment.

In the event that I fail to pass the drug screening test or that I do not remain employed by the Company for a period of at least thirty working days, I will be required to reimburse the Company for the testing procedures performed.

ITEMS YOU MUST PROVIDE – In order to be employed by the Henry Carlson Company, an employee must have the following items when reporting to work each day:

• Hard Hat
• Hammer
• Pliers
• 25' Tape Measure
• Utility Knife
• Leather Work Boots (No Tennis Shoes)
• Prescription Safety Glasses (If Prescription Glasses are Needed).
• In a ddition, carpenters will need to provid e standard carpentry hand tools.

In order to be employed by Asphalt Surfacing Company, an employee must have the following items when reporting to work each day:

• Leather Work Boots (No Tennis Shoes)
• Prescription Safety Glasses (If Prescription Glasses are Needed).

WORKING HOURS – Although the regular hours for the Company vary between 7:00 AM and 5:00 PM, the actual working hours are determined by the job superintendent for the crew to which an employee will be assigned.

I have read and understand the requirements for prospective applicants listed above and agree to comply with them in the event of being hired for employment.

I certify that I am at least eighteen years of age.

I certify that the answers given herein are true and comp lete to the best of my knowledge. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

I understand that neither this document nor any offer of employment from the Company constitute an employment contract unless a specific document to that affect is executed by the Company and employee in writing.

I understand that if I am hired and issued a Company hard hat and if I do not remain employed with the Henry Carlson Company/Asphalt Surfacing Company for thirty working days, I will be required to return the Company issued hard hat. I also understand that if I do not return the Company issued hard hat upon departure from employment, the cost will be deducted from my paycheck.