Craft Employment Application

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1 Craft Employment Application Jacobsen Construction is an EEO/AA employer. We welcome all qualified jobseekers. Jobseekers will receive fair and impartial consideration without regard to race, sex, color, religion, national origin, age, disabilities, veteran status, genetic data, or other legally protected status. Application Information (Incomplete information could disqualify you from further consideration. Please COMPLETE ALL fields.) Last Name Street First M.I. Date Apartment/Unit # City State ZIP What position are you applying for? Please check either Yes or No for each question below and write explanations where requested 1. Are you eligible to work in the United States? (If offered employment, you will be required to provide documents to verify eligibility.) 2. Are you at least 18 years of age? 3. Have you been employed by Jacobsen Construction in the past? If yes, please indicate the approximate dates of previous employment and the projects with which you were involved. 4. Have you ever been fired from a job? If so, please explain the details. 5. Are you currently using illegal drugs? 6. Have you ever stolen anything from an employer, co-worker or a job site? 7. Have you ever engaged in fighting or acts of violence in the workplace? 8. Has a drug test ever confirmed that you were working or driving under the influence? 9. Are you presently debarred, suspended, proposed for disbarment, or declared ineligible for the award of contracts by any agency of the United States Government? 10. Are you employed now? If yes, by whom? 11. If you answered yes to #10, may we contact your present employer? 12. Are you willing to travel or relocate for work? If yes, for what duration of time: 1-3 months 13. When are you available to start work? Date: 14. Which days are you available for work? 4-6 months more than 6 months SU M T W TH F SA 15. When are you available for work? Full Time Part Time Shift Work Temporary Summer Only Details: Jacobsen Construction Co., Inc. Employment Application page 1 of 11

2 Work History List your most recent employer first, including U.S. Military service. You may attach a resume to this application. Explain, in detail, any gaps in your employment history, including gaps reflected in any attached resume. For example, if in school, provide name of school, dates attended and course of study. You may attach an additional page. You may include time spent completing apprenticeships; please include the trade in which you apprenticed. You may exclude any information indicating race, color, sex, religion, national origin, age, disability, veteran, and/or other protected status. Supervisor Job Title Responsibilities Starting Salary $ Ending Salary $ Reason for Leaving Did this position include supervisory duties? If, how many employees were supervised? Supervisor Job Title Responsibilities Starting Salary $ Ending Salary $ Reason for Leaving Did this position include supervisory duties? If, how many employees were supervised? Supervisor Job Title Responsibilities Starting Salary $ Ending Salary $ Reason for Leaving Did this position include supervisory duties? If, how many employees were supervised? Supervisor Job Title Responsibilities Starting Salary $ Ending Salary $ Reason for Leaving Did this position include supervisory duties? If, how many employees were supervised? Supervisor Job Title Responsibilities Starting Salary $ Ending Salary $ Reason for Leaving Did this position include supervisory duties? If, how many employees were supervised? Jacobsen Construction Co., Inc. Employment Application page 2 of 11

3 Work History High School Did you graduate? GED College or University Did you graduate? Degree Trade or Tech School Did you graduate? Degree Special Training: Please list any special training you ve had, including: courses, seminars, licenses, and/or certifications. References Please list three professional references Full Name Relationship # Full Name Relationship # Full Name Relationship # Referral Source How did you learn about Jacobsen Construction? Please check all boxes which apply. I saw your advertisement in the newspaper. Name the paper: I heard your advertisement on the radio. Name the station: I was referred by Dept. of Workforce Services (Job Service). I worked for a subcontractor on one of Jacobsen s Projects. Name the subcontractor: I noticed a Jacobsen trailer at a job site. A friend, relative or acquaintance referred me. Name: Does the person named above work for Jacobsen? Other. Please explain: Jacobsen Construction Co., Inc. Employment Application page 3 of 11

4 Essential Job Functions Please indicate, by checking the appropriate box below, whether you are able to perform each essential job function, with or without accommodation. I am able to regularly and predictably attend work, and dependably arrive at work on time as scheduled. I am able to handle/carry a sheet of plywood or gypsum board, measuring 4 x 8 x ¾, weighing 70 pounds. I am able to handle/carry materials weighing up to 70 pounds. I am able to lift/place materials weighing up to 70 pounds above my waist. I am able to perform work in areas that may require me to crouch or kneel. I am able to accurately drive stakes using a 5 pound hammer. Able Without Accommodation Able With Accommodation Unable to Perform Essential Function I am able to climb stairs, ladders, scaffolding, and form work safely. I am able to grasp tools, materials, and equipment using my hands. I am able to perform work that may require me to use force to push/pull or lift/carry. I am able to perform hand excavation using a pick and shovel. I am able to grip/operate small electrical tools (e.g. air compressor, 5KW generator, sandblaster with pot, chipping guns, busing hammers, etc.) I am able to grip/operate small hand tools (e.g. drills, saws, screwdrivers, etc.) I am able to read/understand a measuring tape. I am able to understand and analyze measurements. I am able to do basic math (e.g. add, subtract, multiply, and divide). I am able to work in poor weather where my footing may be wet or slippery. I am able to work on uneven terrain without falling. I am able to accurately follow my supervisor s directions. I am able to communicate in English with supervisors and other craft persons. I am able to hear and understand instructions or warnings from supervisors and other craft persons. I am able to read simple instructions in English. I am able to work in an environment that is generally outside. I am able to work in an environment that is dusty and noisy. Jacobsen Construction offers reasonable accommodations to all applicants for employment and to qualified individuals with a disability to perform the essential functions of their job or the job they are seeking. If you are an individual with a disability and require an accommodation, please contact Human Resources at or HR-Dept@JacobsenConstruction.com. Jacobsen Construction Co., Inc. Employment Application page 4 of 11

5 Construction Experience Please check the areas in which you have a minimum 6 months experience. ROUGH CARPENTRY Form Building Footings Foundation Walls Columns Stairs Slabs on Grade Suspended Slabs Walls - 20 or Higher Forming Systems Architectural Forms Flying Form System Gang Forms Alumiform System EFCO System Gates System Hand-Set Forms Symons Forms Framing Bocking / Backing Wood Framing Metal Stud Framing Wood Nailers Other Log Structures SHORING Site Work - Retaining Walls Multi-level Suspended Slabs Underpinning Scaffold Building FINISH CARPENTRY Exterior Finish Doors & Windows Interior Finish Cabinetry Doors & Hardware Sheetrock Hanging Sheetrock Taping Specialties & Accessories Stairs Windows Wood Trim / Mouldings LAYOUT Interior Layout Laser Level Operation Print Reading Site Layout Surveying tal Station Operation Transit Use Theodolite Use CONCRETE FINISHING Curb and Gutter Large Commercial Flatwork Residential/Small Commercial Riding Trowel/Walk Behind Site Concrete (sidewalks) Slabs (SOGs, SOMDs) Stairs EQUIPMENT OPERATION Backhoes, Dozers, Excavators Cranes Rigging Equipment Maintenance Forklift Current CDL Class: A B C OTHER EXPERIENCE Rebar Tying Certified Flagging Experience Cert. Expires Certified Welding Cert. Type(s) Expires Non-certified Welding Type(s) ol List Please check all tools you currently own. Note: You will be expected to bring these tools to the job site on your first day of work. Adjustable wrench: 10 Bucket 5 gallon Chipping hammer Combination or speed square Edger: ½ Float: magnesium Framing square Hammer: 16 oz. min, recommend fiberglass handle Hand stone Knee pads with hard caps Pliers: cutting and side cut Pry bar and cat s paw Sliders Tape measure: 100 Trowel: large (16 x 4, 20 x 4, or larger) Trowel: Brunner finish trowel (12 x 3 ) Trowel: margin trowel Water brush Adjustable wrench: 12 Chalk box Cold chisel Edger: ¼ Float: fiberglass Float: rubber Gloves: leather recommended Hammer: 20 oz. min, recommend fiberglass handle Knee boards Level: 48 Plumb bob: 8 oz. min Screwdriver: Large Flat-head Tape measure: 25 or 30 ol belt, box or bag Trowel: medium (12 x 4 ) Trowel: wall trowel (8 x 3 ) Utility knife Jacobsen Construction Co., Inc. Employment Application page 5 of 11

6 Applicant s Attestation and Agreement Please read each statement below and add your initials next to each statement. By my initials and signature below, I hereby acknowledge and consent to the following: I certify that the information contained in this application, and any attached resume, is true and complete. I attest to the fact that the answers given by me are correct to the best of my knowledge and ability. I certify that I have not knowingly withheld any information that might affect my chances for hire. I understand that any false information or omission (including any misstatement) on this application or on any document used to secure this employment can be grounds for rejection of my application or, if I am employed by Jacobsen Construction, can be grounds for my immediate termination from Jacobsen Construction. I authorize Jacobsen Construction to check and verify any and all information listed above, including but not limited to my references, record of employment, education record, and any other information I have provided. Unless otherwise noted, I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. I release the company, my former employers and all other persons and entities, from any and all claims, demands or liabilities arising out of or in any way related to such examination or revelation. I understand that should I be offered employment at Jacobsen Construction, all offers are contingent upon satisfactory completion of Jacobsen s pre-employment screening process, which may include the following components, depending on the position I am offered. I understand that specific disclosures and authorizations will be collected at the time an offer of employment is extended. Credit report and history Criminal background report DOT fitness for duty physical Drug screening Employment verification Motor vehicle record review Professional reference check Verification of past employment Verification of education and professional licenses/certifications I understand that this application is not a contract, offer or promise of employment and that if hired, I will be an at-will employee. As such, I will be able to resign at any time for any reason. Likewise, Jacobsen Construction can terminate my employment at any time with or without cause, unless otherwise required by law. I further understand that no one other than Jacobsen Construction has the authority to enter into an employment contract or agreement with me and that my at-will employment can be changed only by a written agreement. Signature Printed Name Date This application is valid only for 60 days from the date signed / dated above. Jacobsen Construction Co., Inc. Employment Application page 6 of 11

7 Pre-Employment Equal Employment Opportunity Voluntary Self Identification Why are you being asked to complete this form? Jacobsen Construction, Inc. (Jacobsen) is subject to Executive Order 11246, as amended, which requires Federal contractors to ensure that applicants are employed and that employees are treated during employment without regard to their race, color, religion, sex, sexual orientation, gender identity, or national origin. We are therefore requesting information about race and gender in order to comply with government reporting requirements and in order to ensure equal employment opportunity. Submission of this information is voluntary, refusal to provide it will not subject you to any adverse treatment. Information you submit will be kept confidential and will be used solely to assist us in complying with Federal and State Equal Employment Opportunity and Affirmative Action record keeping requirements. Please note: This form is T part of your official application for employment. This information will be recorded and maintained in a confidential file, separate from all other records. Application Information Printed Name: Date: MALE FEMALE I CHOOSE T TO SELF-IDENTIFY Please select ONE OR MORE of the following Equal Opportunity Identification Groups that apply to you: HISPANIC or LATI A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin WHITE A person having origins in any of the original peoples of Europe, the Middle East or North Africa BLACK or AFRICAN AMERICAN A person having origins in any of the black racial groups of Africa ASIAN A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER A person having origins in any of the original peoples of Hawaii, Guam, Samoa or other Pacific Island AMERICAN INDIAN or ALASKA NATIVE A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment I CHOOSE T TO SELF-IDENTIFY Jacobsen Construction Co., Inc. Employment Application page 7 of 11

8 Voluntary Self-Identification of Disability Why are you being asked to complete this form? Form CC-305 OMB Control Number Expires 1/31/2020 Page 1 of 2 Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities. i help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way. If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier. How do I know if I have a disability? You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition. Disabilities include, but are not limited to: Blindness Autism Bipolar disorder Post-traumatic stress disorder (PTSD) Deafness Cerebral palsy Major depression Obsessive compulsive disorder Cancer HIV/AIDS Multiple sclerosis (MS) Impairments requiring the use of a wheelchair Diabetes Epilepsy Schizophrenia Muscular dystrophy Missing limbs or partially missing limbs Intellectual disability (previously called mental retardation) Please check one of the boxes below:, I HAVE A DISABILITY (or previously had a disability), I DON T HAVE A DISABILITY I DON T WISH TO ANSWER Your Name day s Date

9 Voluntary Self-Identification of Disability Reasonable Accommodation Notice Form CC-305 OMB Control Number Expires 1/31/2020 Page 2 of 2 Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment. i Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor s Office of Federal Contract Compliance Programs (OFCCP) website at PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.

10 Vietnam Era Veterans Readjustment Assistance Act of 1974 as Amended Pre-Employment Voluntary Self Identification of Veteran Status Page 1 of 2 Why are you being asked to complete this form? Jacobsen is also a Government contractor subject to the Vietnam Era Veterans Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment veterans in the following classifications: A disabled veteran is one of the following: A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or A person who was discharged or released from active duty because of a service-connected disability. A recently separated veteran means any veteran during the three-year period beginning on the date of such veteran s discharge or release from active duty in the U.S. military, ground, naval, or air service. An active duty wartime or campaign badge veteran means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense. An Armed forces service medal veteran means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order Protected veterans may have additional rights under USERRA The Uniformed Services Employment and Reemployment Rights Act. In particular, In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor s Veterans Employment and Training Service (VETS), toll-free, at USA-DOL. As a Government contractor subject to VEVRAA, we are required to submit a report to the United Stated Department of Labor each year identifying the number of our employees who are protected veterans. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information provided will be used only in ways that are consistent with the Vietnam Era Veterans Readjustment Assistance Act of 1974, as amended. Jacobsen Construction Co., Inc. Employment Application page 10 of 11

11 Vietnam Era Veterans Readjustment Assistance Act of 1974 as Amended Pre-Employment Voluntary Self Identification of Veteran Status Page 2 of 2 Reasonable Accommodation Notice If you are a disabled veteran it would assist us if you tell us whether there are accommodations we could make that would enable you to perform the essential functions of the job, including special equipment, changes in the physical layout of the job, changes in the way the job is customarily performed, provision of personal assistance services or other accommodations. This information will assist us in making reasonable accommodations for your disability. The information you submit will be kept confidential, except that (i) supervisors and managers may be informed regarding restrictions on the work or duties of disabled veterans, and regarding necessary accommodations; (ii) first aid and safety personnel may be informed, when and to the extent appropriate, if you have a condition that might require emergency treatment; and (iii) Government officials engaged in enforcing laws administered by the Office of Federal Contract Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed. If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below. I IDENTIFY AS ONE OR MORE OF THE CLASSIFICATIONS OF PROTECTED VETERAN LISTED ABOVE I AM T A PROTECTED VETERAN I CHOOSE T TO SELF IDENTIFY Printed Name: Date: Once your application has been printed and signed, please it to: hr-dept@jacobsenconstruction.com Jacobsen Construction Co., Inc. Employment Application page 11 of 11

TEMPORARY LECTURER APPLICATION FOR EMPLOYMENT

TEMPORARY LECTURER APPLICATION FOR EMPLOYMENT California State University, Chico Office of Faculty Affairs Chico, California 95929-0024 Voice 530-898-5029 Position Title: Department: To comply with the