Internal Use Only

BARTOW PRECAST, INC.

EMPLOYMENT APPLICATION

Job Offer Date: _____________
Job Offer By: _______________Start Date: _________________

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race,color, religion, gender, age, national origin, sexual orientation, marital status, veteran status, genetics, non-job related disability, or any otherprotected group.

Date ofApplicant Name _________________________________________________________________ Application _______________(First)(Middle)(Last)
Social Security #: ___________________________________

Position Applied For ___________________________________

Address _________________________________________________________________ How Long ? ____________(Street)(City)(State & Zip Code)

Mailing Address (if different from street address) ___________________________________________________________

Telephone # ___________________________________ E-Mail Address _____________________________________________EDUCATIONSCHOOL LEVELSCHOOL NAME & CITY/STATEGRADUATE(Yes or No)

AREA OF STUDY OR DEGREE

HIGH SCHOOLCOLLEGECOLLEGETECHNICAL

LIST ADDITIONAL COURSES OR CONTINUING ED CLASSES THAT ARE RELEVANT TO THE POSITION APPLIED FOR:_________________________________________________________________________________________________________
LIST SKILLS OR MACHINERY & EQUIPMENT YOU HAVE WORKED WITH THAT ARE RELEVANT TO THE POSITION:__________________________________________________________________________________________________________________________________________________________________________________________________________________

EMPLOYMENT HISTORY(Attach sheet if more space is needed)
Must list the complete accurate mailing address and phone number. Candidates whose employment history cannot be
verified will not be considered.
List employers in reverse order starting with the most recent. Gaps in employment must be explained.

EMPLOYER NAME _____________________________________________________________________________________________________ADDRESS ____________________________________________________________________________ PHONE _________________________CONTACT PERSON _______________________________________________ E-MAIL ADDRESS OR FAX # ____________________________POSITION HELD ______________________________________________________ FROM ___________________ TO ___________________JOB DUTIES ___________________________________________________________________________________________________________REASON FOR LEAVING _________________________________________________________________________________________________EMPLOYER NAME _____________________________________________________________________________________________________ADDRESS ____________________________________________________________________________ PHONE _________________________CONTACT PERSON _______________________________________________ E-MAIL ADDRESS OR FAX # ____________________________POSITION HELD _______________________________________________________ FROM ___________________ TO __________________JOB DUTIES ___________________________________________________________________________________________________________REASON FOR LEAVING _________________________________________________________________________________________________EMPLOYER NAME _____________________________________________________________________________________________________ADDRESS ____________________________________________________________________________ PHONE _________________________CONTACT PERSON _______________________________________________ E-MAIL ADDRESS OR FAX # ____________________________POSITION HELD _______________________________________________________ FROM ___________________ TO __________________JOB DUTIES ___________________________________________________________________________________________________________REASON FOR LEAVING _________________________________________________________________________________________________HAVE YOU SERVED IN THE U.S. ARMED FORCES?  Yes

 No

 Currently Serving

BRANCH : __________________IS THERE ANY REASON YOU MIGHT BE UNABLE TO PERFORM THE FUNCTIONS OF THE JOB FOR WHICH YOU ARE
APPLYING?  Yes
 NoIf Yes, please explain any reasonable accommodation you may require:__________________________________________________________________________________________________________________________________________________________________________________________________________________ARE YOU OVER THE AGE OF 18?

 Yes

 NoIf No, can you provide proof of age?  Yes

DO YOU HAVE THE LEGAL RIGHT TO WORK IN THE UNITED STATES?

 Yes

 No

IF HIRED, WILL YOU HAVE TRANSPORTATION TO AND FROM WORK?

 Yes

 No

 NoBARTOW PRECAST, INC. IS A CERTIFIED DRUG FREE WORKPLACE. IF HIRED, ARE YOU WILLING TO SUBMIT TO ANDPASS A CONTROLLED SUBSTANCE TEST?
 Yes
 No

TO BE READ AND SIGNED BY APPLICANT
I authorize Bartow Precast, Inc. to make such investigations and inquiries of my personal, employment, financial, and other related matters as may benecessary in arriving at an employment decision. I hereby release employers, schools, and other persons from all liability in responding to inquiries
and releasing information in connection with my application.
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 that I am required to abide by all rules and regulations of the Company.
I also certify that I have completed this application and that all entries on it and information in it are true and complete to the best of my knowledge.

SIGNATURE ______________________________________________________________________ DATE ______________________________

BACKGROUND SCREENING

Bartow Precast, Inc. conducts a background screening as part of our hiring process. You will receive anemailed invitation from applications@PSIbackgroundcheck.com where you will be able to complete allforms online.
Once you receive the email from PSI, please be sure to complete all forms quickly, completely, andlegibly. Errors and omissions will delay the screening and the hiring process.

My email address is: __________________________________________________________________BARTOW PRECAST, INC.
Pre-Employment Drug Testing Consent and Release FormI hereby consent to submit to urinalysis and/or other tests as shall be determined by BARTOW
PRECAST, INC. in the selection process of applicants for employment, for the purpose ofdetermining the drug content thereof.
I agree that Cartersville Occupational Medicine (or other facility hired by the Company) may collectthese specimens for these tests and may test them or forward them to a testing laboratory for analysis.
I further agree to and hereby authorize the release of the results of said tests to the Company.
I understand that it is the current use of illegal drugs that would prohibit me from being
employed at this Company.
I further agree to hold harmless the Company and its agents (including the above-named
physician or clinic) from any liability arising in whole or part out of the collection of specimens,
testing, and use of the information from said testing in connection with the Company’s
consideration of my application of employment.
I further agree that a reproduced copy of this Pre-Employment Consent and Release Form shallhave the same force and effect as the original.
I have carefully read the foregoing and fully understand its contents. I acknowledge that mysigning of this Consent and Release Form is a voluntary act on my part and that I have not been
coerced into signing this document by anyone.
APPLICANT:
Printed Name:

S.S. #:

Signature:

Date:

WITNESS:
Printed Name:
Signature: