Pre-Job Essential Functions and Evaluation

Listed below are the essential functions and physical requirements pertaining to jobs for which you are applying. These bona fide requirements are essential to the job and are in addition to skills, certifications, years of experience or other qualifications required to perform the job(s) for which you are applying. The questions set forth in this document are ADA and EEOC compliant. If you state you desire not to perform an essential function, it will be considered the same as you cannot perform it.

Please consider each function carefully and check the ones you can perform.

Lift up to 20 pounds

Carry up to 20 pounds

Lift up to 40 pounds

Carry up to 40 pounds

Reach overhead with 25 to 35 pounds

Climb stairs or ladders

Squatting / Stooping / Bending

Prolonged Standing / Walking

Pushing / Twisting / Pulling

Repetitive motion with right hand

Repetitive motion with left hand

Gripping or grasping with right hand

Gripping or grasping with left hand

Twisting with right hand

Twisting with left hand

Work around dust, solvents, paint or chemicals

Hear alarms and/or signals

Work in prolonged cold environment

Work in prolonged hot environment

Climb stairs with loads

I understand that falsification of this document may result in refusal to hire me or termination of my employment.

Signature: Date: