Bridgeport Materials, Inc.

310 North Derby Lane #380

North Sioux City, South Dakota 57049-7619

Lieberconstruction.com

Office: 605.422.0543

Fax: 605.422.0544

Applicants are held for 90 days. Lieber Construction does not discriminate against someone (applicant or employee) because of that person’s race, color, religion, sex (including gender identity, sexual orientation, and pregnancy), national origin, age, disability or genetic information.

Name: ______

FirstMiddle Last

Address: ______

Home Phone: ______Cell Phone: ______

SSN: _____/_____/______DOB: _____/_____/_____DL#: ______STATE: ______

In case of emergency, who should we contact: ______Telephone #: ______

Date of Application: _____/______/______

Position Applied for: ______Full Time: _____ Part Time: _____

Have you work for Lieber Construction before: _____ If yes, when? ______

Reason for leaving: ______

When are you available to begin work: _____/_____/_____

Are you a US Citizen or otherwise legally authorized to work in this country? Yes______No______

Have you ever been convicted of a felony? Yes______No______

If yes, when? _____/_____/______

-A conviction record will not necessarily make you ineligible for employment

-Factors such as time, situation factors, seriousness, and nature of the violation will be taken into account

Have you been convicted of driving under the influence of drugs/alcohol within the last 5 years? Yes____ No____

If yes, when? ______

Have you ever had your driver’s license suspended or revoked? Yes______No______

Do you drink alcohol? Yes ____ No ____

Do you currently use drugs illegally? Yes ____ No ____

Highest grade level completed? High School: (please circle) 9 10 11 12 College: Associates Bachelor’s

Employment Record:

Latest employment first: Please include military service, self-employment, and periods of unemployment

Employer Name: ______Supervisor: ______

Address: ______Telephone: ______

Dates of Employment: _____/_____/_____ thru _____/______/_____ Rate of Pay: ______

Are you presently employed? Yes ____ No____May we contact this employer? Yes ____ No ____

Reason for leaving: ______

Employer Name: ______Supervisor: ______

Address: ______Telephone: ______

Dates of Employment: _____/_____/_____ thru _____/______/_____ Rate of Pay: ______

Are you presently employed? Yes ____ No____May we contact this employer? Yes ____ No ____

Reason for leaving: ______

Employer Name: ______Supervisor: ______

Address: ______Telephone: ______

Dates of Employment: _____/_____/_____ thru _____/______/_____ Rate of Pay: ______

Are you presently employed? Yes ____ No____May we contact this employer? Yes ____ No ____

Reason for leaving: ______

I hereby acknowledge that prior to submitting this application. I have been informed that the information provided herein may be used to conduct current and previous employers, references or any other individuals this company considers necessary.

I hereby authorize my current and previous employers, references, and other individuals contacted by this company to release past or present information requested, including but not limited to past drug and alcohol test results. I release all providers of said information from any liability stemming from release of same information.

I understand that as an employee at will, I have the right to terminate my employment at any time and therefore Lieber Construction holds the same right.

Date: ____/_____/_____

Applicant Name: ______

Applicant Signature: ______