Date of Application *

MM

DD

YYYY

Name *

First Name

Last Name

Any Other Name Used

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone *

(###)

###

####

Cell Phone *

(###)

###

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Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you have the legal right to work in the United States? *

(Upon employment, you will be required to furnish written proof of your right to work in the United States and identification.)

Yes

No

Are you at least 18 years of age? *

Yes

No

Have you ever committed or been convicted of a crime other than a minor traffic violation? *

(Commission or conviction of a crime is not an automatic bar to employment. All circumstances will be considered.)

Yes

No

U.S. Military Service *

Are you a member of the National or State Guard or Active Reserve?

Yes

No

Have you ever worked for the company? *

Yes

No

If so, when?

MM

DD

YYYY

Are you presently employed? *

Yes

No

May we contact your present employer?

Yes

No

Name of employer:

First Name

Last Name

Employer address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Can you travel if job requires it? *

Yes

No

Date available to begin work: *

MM

DD

YYYY

Reference 1 *

First Name

Last Name

Phone *

(###)

###

####

Reference 2 *

First Name

Last Name

Phone *

(###)

###

####

Reference 3 *

First Name

Last Name

Phone *

(###)

###

####

Name of Supervisor *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Date Left *

MM

DD

YYYY

Name of Supervisor

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Date Left

MM

DD

YYYY

Name of Supervisor

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Date Left

MM

DD

YYYY

AGREEMENT *

I, the undersigned, agree to the following: (1) That all information supplied in this application and any attached resume is true and correct and that any false or misleading information furnished by me regarding my application will be sufficient cause for rejection of this application or immediate dismissal if employed by the Company; (2) That, if such is required, I will take a drug/alcohol screen test during the application process or during employment if hired, and, if required, will submit to a physical examination after a conditional offer of employment, if one is made, or during employment if hired and will permit the results to be released to the Company and to release all persons and companies from any liability arising out of such examination or testing; (3) That during my employment with the Company, if hired, I will report to the Company any drug-related criminal conviction within five days of that conviction; (4) That if hired, I agree to abide by and observe all Company rules and regulations and agree that my employment is at-will and can be terminated with or without cause and with or without notice at any time at either the option of the Company or the employee and that those terms can only be modified by the President of the Company, in writing, provided that such writing specifically acknowledges that it is a modification of this agreement and is signed by the President; (5) That no supervisor, agent, representative or employee of the Company has now or has had in the past any authority to enter into any agreement or employment for a specified period of time, or to make any agreement which is contrary to or a modification of the above terms, nor can any policies of the ·company, either written or oral, modify the above terms; (6) That if hired, I may be on a ninety (90) day introductory period during which time I may be discharged without recourse; and (7) That the use of this application form does not indicate there are any positions open and does not in any way obligate the Company.

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AGREEMENT TO ARBITRATE EMPLOYMENT DISPUTES *

I agree that if any dispute or controversy arises out of or relates to my employment or breach of my employment, which cannot be settled through discussion or negotiation, to use binding arbitration in accordance with the rules of the American Arbitration Association as the only method to resolve unsettled claims that are recognized in a court of law. Interpretations will be according to Mississippi law unless Federal law prevails. In either case, all discussions and proceedings will be in Jackson, Mississippi. By way of example only, such disputes include claims under federal, state, and local statutory or common law, such as the Age Discrimination in Employment Act, Title VI of the Civil Rights Act of 1964, as amended, including the amendments of the Civil Rights Act of 1991, the Americans with Disabilities Act, the Equal Pay Act, the law of contract, and the law of tort.

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RELEASE *

I, the undersigned, authorize all educational institutions which I have attended, all branches of U.S. military service in which I have served, all of my former and present employers, all credit bureaus, all court systems and all of the representatives of those organizations to furnish Floore Industrial Contractors, Inc., or its associated companies or representatives any and all information concerning my education, military service, former employment, credit history and/or criminal convictions. In addition, I hereby agree to hold harmless and to release all of said organizations, institutions, services, employers, bureaus, courts and representatives from any and all claims that I may have, or which may arise, against any and/or all of them, including Floore Industrial Contractors, Inc., its associated companies and representatives as a result of their furnishing information to Floore Industrial Contractors, Inc., its associated companies or representatives.

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