Job Applying For:   When Could You Start:   How Did You Learn About Us? News Paper Employment Agency UPCI Posters Employee Referral Other PERSONAL INFORMATION: First Name:   Middle Name:   Last Name:   Street:   City:   State:   Zip Code:   Phone:   Social Security #:   If hired, can you provide proof within 3 days or submit verification of your legal right to work in the United States? YesNo Do you possess a valid Drivers license? Yes No Do you have a commercial drivers license? YesNo Federal law requires 18 years of age or more. Do you meet this requirement? YesNo Are you will to accept employment that requires you to travel? YesNo Check applicable classifications/machines you are qualified for and indicate years of experience: Asphalt Grinders Mill Finish Blade Rough Blade Haul Road Blade Scraper Front End Loader Excavator Trimmer Skid Steer Concrete Paver Concrete Spreader Concrete Plant Concrete Saw Roller Farm Tractor Truck Driver Water Truck Driver Aircompressor Tar Kettle Concrete Finisher Form Setter Carpenter Welder Mechanic Mechanic Helper Laborer Flagger Sealing Additional questions and comments: EDUCATION AND/OR TRAINING: Certain positions require education high school or above. Have you completed: High School? College? Trade/Vocational? Other? Yes No Yes No Yes No Yes No EMPLOYMENT BACKGROUND: Please list your work experience beginning with your most recent job.   1 2 3 Name Of Company: Address: City and State: Employment Dates: From/To From/To From/To Salary: Start/Last Start/Last Start/Last Title: Last Supervisor: Describe Your Duties: Reason For Leaving(Explain): Phone Number: May we contact your present employer? YesNo REFERENCES: All previous employers are considered as references unless specific advice to the contrary accompanies this application. Name below, in addition, at least three other persons who may contacted. Name Address: Street, City, State Occupation Phone # Have you ever been employed with Upper Plains Contracting, Inc. in the past? Yes No Have you ever been convicted of a crime, felony, or misdemeanor? Yes No I hereby affirm and declare that all foregoing statements are true and correct and that I have not knowingly withheld any fact that would, if disclosed, affect my application unfavorably, and hereby authorize the company to conduct any investigation together with their opinions on these matters without any liability for any damage whatsoever caused either directly or indirectly by giving this or receiving the information or opinions. I authorize my former and present employers to give any information they may have concerning my character, health and employment record. It is understood that false statement(s) on this application may be considered as sufficient cause for rejection of this application, or dismissal, if already employed. Upper Plains Contracting, Inc. is in compliance with the Equal Employment Opportunity Act and all other appropriate Federal and State Laws.

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