Date of Application:

Have you applied before?

Yes

If so, when?

Have you been employed with us before?

Yes

If yes, from what date to what date?

Last Name:

First Name:

Address:

Phone:

Can you provide required proof of your eligibility and legal age to work?

Yes

If applying for a position that requires driving, have you been ticketed for a moving traffic violation?

Yes

If yes, please explain:

Date available for work?

Type of work desired?

Full Time

Part Time

Temporary

If temporary, indicate dates available:

**The following page 1 questions will help us to qualify you for employment at Pedersen Excavating. You are not required to respond. Equipment Operated:

**The following questions will help us to qualify you for employment at Pedersen Excavating. You are not required to respond. Equipment Operated:

Skid Steer

Blade

Dump Truck

Excavator

Loader

Scraper

Dozer

From the options picked above, how long did you operate? *Please list individually.

Valid Operator's License?

Yes

CDL?

Yes

Number:

State:

CDL Endorsments (CHECK ALL THAT APPLY)

T - Double/Triple Trailers

P - Passengers

N - Tank Vehicles

H - Hazardous Materials

X - Combination Tank and Hazardous

An Equal Opportunity Employer

Employment History

Start with your present or most recent employer and DO NOT SKIP any employment. Include military experience.

First Employer Please include: 1.) employer's name, 2.) the dates you were employed, 3.) employer's address & phone #, 4.) your title, 5.) supervisor, 6.) hourly rate (starting & ending), 7.) work performed, 8.) reason for leaving

Second Employer Please include: 1.) employer's name, 2.) the dates you were employed, 3.) employer's address & phone #, 4.) your title, 5.) supervisor, 6.) hourly rate (starting & ending), 7.) work performed, 8.) reason for leaving

Third Employer Please include: 1.) employer's name, 2.) the dates you were employed, 3.) employer's address & phone #, 4.) your title, 5.) supervisor, 6.) hourly rate (starting & ending), 7.) work performed, 8.) reason for leaving

References

Do not include family members or past supervisors

First Reference Please include: 1.) Name, 2.) Phone, 3.) Occupation, 4.) Best time to call

Second Reference Please include: 1.) Name, 2.) Phone, 3.) Occupation, 4.) Best time to call

Third Reference Please include: 1.) Name, 2.) Phone, 3.) Occupation, 4.) Best time to call

Education

First School Please include: 1.) School, 2.) Location, 3.) Number of years completed, 4.) Diploma/Degree

Second School Please include: 1.) School, 2.) Location, 3.) Number of years completed, 4.) Diploma/Degree

Third School Please include: 1.) School, 2.) Location, 3.) Number of years completed, 4.) Diploma/Degree

Miscellaneous

Describe any specialized training, apprenticeship, or skills

List any activities, special interests, or hobbies You may exclude organizations which would indicate race, color, religion, sex, national origin, disability, or any other prohibited basis of discrimination, as provided under applicable state and federal law

Have you ever been convicted of a felony in the last seven (7) years?

Yes

If yes, please explain:

Do you have minimum salary requirements?

Yes

If Yes, please specify:

If Yes, will you automatically reject all offers or positions with a lower starting salary?

Yes

Please include additional information you feel may be helpful to us in considering your application

Applicant's Knowledge

I certify that the information provided in this application for employment is true, correct, and complete. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. If as a candidate for employment I provide false or misleading information, my application or offer of employment will be cancelled indefinitely. I authorize complete investigation of all information provided in this application for employment. I hereby release from liability Pedersen Excavating Inc. and its representatives in securing job-related information from the sources I have listed herein. I also release my sources listed to provide such job-related information as may be requested by Pedersen Excavating Inc. This application for employment will be considered current and active for a period of 45 days following the date of submission. If I am considered for a position at any time after today, I will be asked if anything on my application has changed, and if so, I will be required to update my application accordingly. I understand that neither this document nor any offer of employment from Pedersen Excavating Inc. constitutes an employment contract. Pedersen Excavating Inc. is an equal opportunity employer. Applicants are considered for all positions, and employees are treated during employment, without regard to race, color, religion, sex, national origin, disability, or any other prohibited basis of discrimination, as provided under applicable state and federal law. Acceptance of an offer of employment does not create a contractual obligation upon Pedersen Excavating Inc. to continue to employ me. Any employment relationship with this organization is of an "at will" nature which means I may resign at any time and Pedersen Excavating Inc. may terminate my employment any time, with or without cause, with or without notice. If I accept an offer of employment from Pedersen Excavating Inc., I understand that I will be provided a copy of the employee handbook, safety policy, drug-free workplace notice, and other general information as pertains to my employment with this company. I hereby agree to read such materials and abide by the guidelines set forth in each. If I accept an offer of employment from Pedersen Excavating Inc., I will be requested to provide my consent to: 1) a drug screen, 2) pre-employment physical and, 3) enforcement of the Pedersen Excavating Inc. drug and alcohol policy provisions. An offer of employment made by Pedersen Excavating Inc. as a result of this application is specifically conditioned upon a negative drug screen result and completing a pre-employment physical with establishment of the fact that a potential employee may perform essential functions of the job with or without reasonable accommodations. By checking this box you are acknowledging you have read, understand, and consent to the above conditions of employment.

By checking this box, you are acknowledging you have read, understand, and consent to the above conditions of employment.

Employment