Your full name. street address. city. state. zip. phone. email.

Any and/or all below is Optional

The purpose of this page is to assist in monitoring our recruitment efforts and to aid in complying with any
required governmental record keeping or periodic reporting. This information is not part of your employment
application, and will not be considered in the employment/selection process. This infonnation is voluntary and
an applicant will not be subject to any adverse treatment for refusing to complete the questionnaire.
If you choose to provide the information, please complete the following.

Title of Job applied for

Applicant name

Race(please check one)

White- origins in Europe, North America, or Middle East

Asian -origins in Far East, Southeast Asia, India or Pacific Islands

Black- origins in Africa

Hispanic - Mexican, Puerto Rican, Cuban, Central or South American

American Indian -origins in North America, to include Alaska

Gender

male

female

Veterans Status (please check all that apply)

Non-Veteran

Pre-Vietnam Veteran

Vietnam Era Veteran

Post Vietnam Veteran

Reservist

yes no Are you 18 years old or older?
yes no Do you have a valid Driver's License?
license number.
State driver's license issued?
yes no Commercial Drivers License (CDL)?
If CDL, the provide CDL type.
yes no Has your License been revoked or suspended in last 3 years?
If so, please give a short explanation

yes no Did You graduate from high school or receive a GED? Or something equivalent?.
	List any hobbies Or outside interests you may have

Employed From: To:
Payscale From: $ To: $ per year month week day hour
Company Name What was your Position/Title?
State Supervisor's Name and Title?
Explain duties performed while at this company	Please explain your reasons for leaving
Phone (including area code)

Employed From: To:
Payscale From: $ To: $ per year month week day hour
Company Name What was your Position/Title?
State Supervisor's Name and Title?
Explain duties performed while at this company	Please explain your reasons for leaving
Phone (including area code)

Employed From: To:
Payscale From: $ To: $ per year month week day hour
Company Name What was your Position/Title?
State Supervisor's Name and Title?
Explain duties performed while at this company	Please explain your reasons for leaving
Phone (including area code)

List any special skills, Technical or Professional Knowledge you may have:
Have you ever been convicted of a Misdemeanor or Felony?	yes no
If yes, please give a brief explanation of the incident. You may be asked for further explanation at a later time.

Installer Job Description: *   I have read Installer Job Description and I understand the requirements. *  I can perform the job requirements: With reasonable accommodations. Without reasonable accommodations.

Please read the following two Policy Statements
	Adarand's Drug and Alcohol Policy *   I have read Adarand's Drug and Alcohol Policy and I understand and agree to the terms and conditions thereof.
	Adarand's Information Release Authorization Policy: *   I have read Adarand's Information Release Authorization Policy and I understand and agree to the terms and conditions thereof.