PO BOX ***

BROOKLYN, IA *****-****

PHONE: 641-***-**** FAX: 641-***-****

CDL APPLICATION FOR EMPLOYMENT

All applicants who have a CDL must complete this application. NOTE TO THE APPLICANT: This application is used to evaluate your qualifications for employment. Please answer all of the ques- tions on your application accurately. If you fail to do so, you may lose employment opportunities or delay consideration of your em- ployment. This application is not an employment contract. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, disability, age, sex, or any other classification protected by federal, state, or local laws. Additional testing of job-related skills, as well as post-offer pre-employment physical (which will include a drug test) may be required. Position(s) applied for Date of application PERSONAL INFORMATION

Name Email Address Sreet Apt# City State Zip

Home Phone Cell Phone Date of Birth Are you eligible for employment in the United States? Yes No Have you worked for this company before? Yes No Where? Dates: From To Reason for leaving Are you available to work: Full Time Part Time Temporary Summer Only On what date would you be available for work? Are you on lay-off and subject to recall? Yes No Can you travel if job requires it? Yes No

Would you accept employment Out-of-town Statewide Unaccompanied by family? Who referred you? Rate of pay expected EDUCATION

Circle highest grade completed: 1 2 3 4 5 6 7 8 High School: 1 2 3 4 College: 1 2 3 4 Last school attended Name City State

Degree DRIVER LICENSE INFORMATION

License Number State Expiration Date CDL Type: A B Endorsements Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No If yes, explain Has any license, permit or privilege ever been suspended or revoked? Yes No If yes, explain Have you had an OWI in the past 5 years? Yes No ACCIDENT RECORD FOR THE PAST 5 YEARS (ATTACH SHEET IF MORE SPACE IS NEEDED) IF NONE, WRITE NONE TRAFFIC CONVICTIONS/ FORFEITURES FOR PAST 5 YEARS ( OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE EXPERIENCE

What type of trucks or types and makes/models of construction equipment can you operate? Yrs Yrs Yrs What type of trucks or types and makes/models of construction equipment can you repair? List any craft training programs or special courses you have taken DATE

NATURE OF ACCIDENT

(Head-on, Rear-end, Upset, Etc)

FATALITIES INJURIES

Last accident

Next previous

Next previous

LOCATION DATE CHARGE PENALTY

EMPLOYMENT HISTORY

All CDL applicants who have held a CDL for 10 years, must provide the following information on all employers during the preceding 10 years. Entire 10 years must be accounted for. During periods of unemployment, list dates and write

“unemployed” in employer information. If you have not had a CDL for 10 years, provide information back to the date you first obtained CDL license. List employers starting with most recent first. Add additional sheet if necessary. EMPLOYER EMPLOYED FROM (MO) (YR)

NAME TO ( MO) (YR)

ADDRESS POSITION

CITY STATE ZIP SALARY / WAGE

SUPERVISOR REASON FOR LEAVING

PHONE NUMBER MAY WE CONTACT? YES NO

FAX NUMBER 1ST CDL EMPLOYER? YES NO

EMPLOYER EMPLOYED FROM (MO) (YR)

NAME TO ( MO) (YR)

ADDRESS POSITION

CITY STATE ZIP SALARY / WAGE

SUPERVISOR REASON FOR LEAVING

PHONE NUMBER MAY WE CONTACT? YES NO

FAX NUMBER 1ST CDL EMPLOYER? YES NO

EMPLOYER EMPLOYED FROM (MO) (YR)

NAME TO ( MO) (YR)

ADDRESS POSITION

CITY STATE ZIP SALARY / WAGE

SUPERVISOR REASON FOR LEAVING

PHONE NUMBER MAY WE CONTACT? YES NO

FAX NUMBER 1ST CDL EMPLOYER? YES NO

EMPLOYER EMPLOYED FROM (MO) (YR)

NAME TO ( MO) (YR)

ADDRESS POSITION

CITY STATE ZIP SALARY / WAGE

SUPERVISOR REASON FOR LEAVING

PHONE NUMBER MAY WE CONTACT? YES NO

FAX NUMBER 1ST CDL EMPLOYER? YES NO

EMPLOYER EMPLOYED FROM (MO) (YR)

NAME TO ( MO) (YR)

ADDRESS POSITION

CITY STATE ZIP SALARY / WAGE

SUPERVISOR REASON FOR LEAVING

PHONE NUMBER MAY WE CONTACT? YES NO

FAX NUMBER 1ST CDL EMPLOYER? YES NO

REFERENCES

Include only individuals familiar with your work ability. Do not include relatives. PART 40.25(j) requires Manatts to ask applicant/driver whether he/she has tested positive or refused to test on any pre- employment alcohol or drug test administered by an employer to which the applicant/driver applied, but did not obtain safe- ty sensitive transportation work covered by DOT agency alcohol and drug testing rules during the past (2) years. Applicant/driver answer questions listed below:

During the past two (2) years have you tested positive on a pre-employment alcohol or drug test administered by an employer in which you applied for, but did not obtain safety sensitive transportation work covered by Department of Transportation (DOT) drug and alcohol testing rules? Yes No During the past two (2) years have you refused to test on a pre-employment alcohol or drug test administered by an employer in which you applied for, but did not obtain safety sensitive transportation work covered by Department of Transportation (DOT) drug and alcohol testing rules? Yes No If you answered YES to either of the questions above, please explain below and provide documentation of your successful completion of the return-to-duty process required by Part 40 Subpart 0. TO BE READ AND SIGNED BY APPLICANT

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and oth- er related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical histo- ry will be made only if and after a conditional offer of employment has been extended). I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of Manatt’s Inc. Applicant’s Signature Date

NAME PHONE RELATIONSHIP YRS KNOWN

AN EQUAL EMPLOYMENT

OPPORTUNITY EMMPLOYER

Women, minorities, veterans and individuals with

disabilities are encouraged to apply.

VOLUNTARY AFFIRMATIVE ACTION SURVEY

Manatt’s, Inc., is required by state and federal laws to furnish statistical data and to maintain records of certain population characteristics of those applying for jobs with us. The information you supply will be used for statistical purposes only. If you are offered employment with Manatt’s, Inc., it will not be used as employment criteria. Manatt’s, Inc., is an equal opportunity employer, supporting diversity in the workplace. Thank you for your voluntary cooperation in completing this form. Position Applied For: Date:

Name:

Street Address: City: State: Zip:

Gender

Male Female I choose to not self-identify my gender. Referral Source

Iowa Workforce Development (list location)

Advertisement (list newspaper)

Other Employee (name employee)

School (name school)

Online (name website)

Walk In Other

Ethnicity:

White (Not Hispanic or Latino) Asian (Not Hispanic or Latino) Black or African American (Not Hispanic or Latino) American Indian or Alaska Native (Not Hispanic or Latino) Hispanic or Latino Two or More Races (Not Hispanic or Latino) I choose to not self-identify my ethnicity.

NOTICE FOR ALL EMPLOYEES & APPLICANTS

OPERATING STATEMENT

It is the policy of Manatt’s, Inc., to assure that applicants are employed, and that employees are treated during employment, without regard to their race, religion, sex, color, national origin, age, or disability. Such action shall include: employment, upgrading, demotion, transfer; recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensation; and selection for training, including: apprenticeship, pre-apprenticeship, or on-the-job training.

DESIGNATION OF EE0/AA OFFICER

Manatt’s, Inc., has designated Andy Day, PO Box 535, Brooklyn, IA 52211, 1-866-MANATTS, ext 209, as the EEO/AA Officer. The Assistant EEO/AA Officer will be Diane Kilmer, PO Box 535, Brooklyn, IA 52211, 1-866-MANATTS ext 261. Andy Day or Diane Kilmer has the responsibility to effectively administer and promote this Policy, and is assigned adequate authority and responsibility to do so.

TRAINING LETTER

Manatt’s, Inc., is an Equal Opportunity Employer interested in training prospective employees and upgrading present employees through actual on-the-job training programs. Below are listed the job classifications for which training will be provided: Equipment Operator Truck Driver Concrete Finisher

The qualification(s) to be considered for our company’s training program, a prospective trainee must be an employee in good standing and/or have supervisory approval. For further information, copies of outlines of individual job classifications/area training program outlines, you must request them from Andy Day, Human Resources Director, PO Box 535, Brooklyn, IA 52211 or by calling 1-866-MANATTS ext 209.

PRE-OFFER VETERAN SELF ID FORM

This employer is 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. 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications are defined as follows: 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 12985.

Protected veterans may have additional rights under USERRA—the Uniformed Services Employment and Reemployment Rights Act. 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 1- 866-4-USA-DOL.

If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below. As a Government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA. Please select one of the following:

I identify as one or more of the classifications of protected veteran listed above. I am not a protected veteran.

I don’t wish to answer.

Voluntary Self-Identification of Disability

Form CC-305 OMB Control Number 1250-0005

Page 1 of 1 Expires 05/31/2023

Name: Date:

Employee ID:

(if applicable)

Why are you being asked to complete this form?

We are a federal contractor or subcontractor required by law to provide equal employment opportunity to qualified people with disabilities. We are also required to measure our progress toward having at least 7% of our workforce be individuals with disabilities. To do this, we must ask applicants and employees if they have a disability or have ever had a disability. Because a person may become disabled at any time, we ask all of our employees to update their information at least every five years.

Identifying yourself as an individual with a disability is voluntary, and we hope that you will choose to do so. Your answer will be maintained confidentially and not be seen by selecting officials or anyone else involved in making personnel decisions. Completing the form will not negatively impact you in any way, regardless of whether you have self-identified in the past. For more information about this form or the equal employment obligations of federal contractors under Section 503 of the Rehabilitation Act, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs

(OFCCP) website at www.dol.gov/ofccp.

How do you know if you 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:

• Autism

• Autoimmune disorder, for example,

lupus, fibromyalgia, rheumatoid

arthritis, or HIV/AIDS

• Blind or low vision

• Cancer

• Cardiovascular or heart disease

• Celiac disease

• Cerebral palsy

• Deaf or hard of hearing

• Depression or anxiety

• Diabetes

• Epilepsy

• Gastrointestinal disorders, for

example, Crohn's Disease, or

irritable bowel syndrome

• Intellectual disability

• Missing limbs or partially missing

limbs

• Nervous system condition for

example, migraine headaches,

Parkinson’s disease, or Multiple

sclerosis (MS)

• Psychiatric condition, for example,

bipolar disorder, schizophrenia,

PTSD, or major depression

Please check one of the boxes below:

Yes, I Have A Disability, Or Have A History/Record Of Having A Disability

No, I Don’t Have A Disability, Or A History/Record Of Having A Disability

I Don’t Wish To Answer

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.

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