DUNKIN & BUSH, INC.

PO Box 97080  Kirkland, Washington 98083  PHONE (425) 885-7064  FAX (425) 885-3790

APPLICATION FORFIELD EMPLOYMENT

An Equal Opportunity Employer / Drug Free Business / E-Verify Employer

Instructions: This application must be filled out completely and signed to be considered. You are encouraged to attach a résumé and letter of interest. It is our policy to accept applications for open positions only. Applicants who are selected for interviews will generally be contacted by phone within two weeks of receipt of application materials. This application will remain in active status for 30 days.

Date: Position applying for: Laborer

Personal Data
Name / How did you learn about the position?
NewspaperDunkin & Bush Employee
Street Address / Craigslist Web Page
Employment SecurityWalk-in
City, State, ZIP Code / Employment AgencyOther______
Home Telephone
( ) / Mobile Number
( ) / Message Telephone
( ) / Email Address
List other names under which you have attended school, been employed, or been known by:
Are you over 18 years of age? Yes No / Can you perform the essential functions of the position for which you are applying, with or without reasonable accommodation? Yes No
EOE Statement: Dunkin & Bush, Inc. is an Equal Opportunity Employer. Dunkin & Bush provides equal employment opportunity to all qualified applicants and employees. In recruitment, selection, hiring, training, utilization, transfers, compensation, benefits, promotion, disciplinary action, layoffs, termination, or any other personnel action, there will be no discrimination on the basis of race, religion, national origin, sex, gender identity, sexual orientation, age, marital status, the presence of sensory, mental or physical disability, or honorably discharged veteran or military status or any other basis protected by federal, state or local law. All employment decisions are based on nondiscriminatory considerations such as education, training, experience, skill, aptitude, and other work-related factors and on the business needs of Dunkin & Bush.
Education
Have you graduated from high school or received a GED certificate? Yes No
Name of High School / City, State

FOR OFFICE USE ONLY:

Personnel Actions
Date of Interview: / Class Code:
Hire Date: / Starting Rate of Pay:
Rehire Date: / Starting Position:

Employment Record List present or most recent experience first. Statements such as “seerésumé” do not substitute for completing any portion of the application. Attach additional sheets as necessary.

Have you previously worked for Dunkin & Bush, Inc? Yes No Dates

Title / Duties
Firm Name
Street Address
CityStateZIP
Supervisor’s Name Telephone ( ) / Starting $Ending $
Dates of Employment (Mo/Yr—Mo/Yr) / Reason for leaving
Title / Duties
Firm Name
Street Address
CityStateZIP
Supervisor’s Name Telephone( ) / Starting $Ending $
Dates of Employment (Mo/Yr—Mo/Yr) / Reason for leaving
Title / Duties
Firm Name
Street Address
CityStateZIP
Supervisor’s Name Telephone( ) / Starting $Ending $
Dates of Employment (Mo/Yr—Mo/Yr) / Reason for leaving
Professional References
Name / Address / Telephone
( ) / Title
Name / Address / Telephone
( ) / Title
Name / Address / Telephone
( ) / Title
Name / Address / Telephone
( ) / Title
Licenses and Certificates: List your professional licenses, permits, and certificates, including First Aid and CPR
License / Type / State / Effective Date / Expiration Date
License / Type / State / Effective Date / Expiration Date
License / Type / State / Effective Date / Expiration Date
Education
Type of School / Name of School / City, State, ZIP / Degree or Diploma / Major
Community or Technical
College
College or University
(Undergraduate)
Other School
Field Equipment Operation / Field Skills
Field Relevant Skills
(Years) / Previous Equipment Operation
(Years) /
Previous QA/QC Experience
(Years) /
Training/Special Certifications
(Level)
Painting Conventional
Painting Airless
Abrasive Blasting
Blast Tracking
Rigging For Containment
Rigging For Scaffolding
Fireproofing
Plural Component
Ultra High Water Jetting
Floor Coatings
*Maximum Height able
to work at
*Able to work on ladders and
scaffolding
Other (list): / Bulk Blast Pot 6-8-Ton
Blast Pot 300-600 Lb
Conventional Paint Pot
Airless Paint Pump
Ultra High Water Jetting
Spider Basket
DH Equipment
Dust Collection Equipment
Compressors 100-675 CFM
Compressors 675 + CFM
Other (list): / DFT Gauge (Banana)
DFT Gauge (Electronic)
Psychrometers
Adhesion Tester
SSPC Surface Preparation Standards
Visual Standards
Volume Solids
Tooke Gauge
Holiday Detection
Chloride Testing
Other (list): / NACE
SSPC
First Aid/ CPR
CDL
Lead
Forklift
Scaffolding
QA/QC
Supervisor
Hazardous Waste
Hiring / Firing
Blueprint Reading
Scheduling
Failure Analysis
Pipeline Operator Qualified
TWIC
Other (list):
Applicant’s Certification and Agreement

Please read carefully

By signing below, I certify the following:
  • The information provided in this application and in any accompanying materials is true and complete, and there is no misrepresentation or falsification in any of the statements or answers to questions. I agree that if an investigation discloses any misrepresentation or falsification, Dunkin & Bush may reject my application for employment or terminate my employment with Dunkin & Bush.
  • I authorize Dunkin & Bush to check my references, my criminal history, my driving record if applicable to the position I am applying for, and any information provided in my application for employment. I authorize Dunkin & Bush to investigate all statements and facts contained in my application for employment.
  • I consent to and authorize any of my former employers and referencesand anyone else with information about my work history, educational or work qualifications, and any pertinent information, personal or otherwise, (“Other Parties”), to provide such information to Dunkin & Bush in response to its inquiry. I release Dunkin & Bush and all Other Parties from all claims, liability, and damages for whatever reason arising out of furnishing this information to Dunkin & Bush or Dunkin & Bush’s use of such information. If employed, I agree that Dunkin & Bush may provide references in the future regarding my work history while in its employ.
  • A photocopy or digital image of this Certification and Agreement shall have the same effect as the original.
  • I understand that any employment relationship I may form with Dunkin & Bush will be at will, meaning either Dunkin & Bush or I may end the relationship at any time for any lawful reason or no reason at all, with or without notice and with or without cause.
  • I understand that any offer of employment I receive is contingent upon passing a post-offer drug test, successful completion of a post-offer functional employment test, passing a respirator use clearance test, signing an arbitration agreement, passing orientation testing, and providing proof of my identity and eligibility to work in the United States. I will present the necessary documents and comply with the testing policies when asked.

Printed Name: Date:
Signature:

DUNKIN & BUSH, INC.

Post-Offer/Pre-Placement Functional Employment Test Policy

Post-offer/pre-placement functional employment tests help create a safer working environment for field employees. Applying sports technology to the industrial worker, comprehensive stress tests monitor heart and musculoskeletal function to detect disease processes, wear and tear syndromes, and many other problems that lead to injuries and disability. Training provided during the tests also helps employees increase their body awareness during work activities to prevent cumulative trauma and to successfully reduce injuries. Furthermore, employee turnover and operating expenses are reduced by maintaining properly qualified personnel in each position. Dunkin & Bush is willing to pay for such services to help its employees remain safe in the workplace and to reduce costs associated with injuries.

As a result, in certain designated job categories, Dunkin & Bush is implementing the WorkSTEPS evaluation program for all prospective employees who receive an employment offer in those job categories. The WorkSTEPS evaluation program has been in effect since 1986, has one of the largest normative databases in the United States, and has proven its success by creating safety in the work place. Recognizing that every job and every employee are different, Dunkin & Bush will use the test results to determine whether or not the employee can safely perform job duties.

As part of its commitment to equal opportunity employment, Dunkin & Bush will provide reasonable accommodations when necessary to enable an otherwise qualified candidate with a disability to participate in testing, provided such accommodations do not cause an undue hardship. Prospective or current employees, who believe they need an accommodation to participate in the testing program, must request such accommodations. To minimize or avoid delays in testing, please advise Dunkin & Bush of the need for any accommodation as soon as possible after receiving a conditional offer of employment.

Effective April 20, 2011, all persons receiving conditional offers of employment in positions involving scaffold building, painting, or laborer’s work will be required to successfully complete a functional employment test. A general description of the testing process follows:

  1. Dunkin & Bush will pay the cost of post-offer/pre-placement functional employment test procedures.
  1. Upon receiving conditional offers of employment, candidates will be given written job descriptions and additional written information regarding the post-offer/pre-placement functional employment test. After carefully reviewing this information and/or consulting with their personal physicians, candidates must complete a release authorizing Dunkin & Bush, WorkSTEPS, and the licensed WorkSTEPS testing facility to conduct the post-offer functional employment tests. Requests for accommodations should be noted on the release. Depending on the nature of the accommodation sought, further discussions and/or medical documentation may be needed to identify an appropriate accommodation. Testing will be delayed until the interactive process aimed at identifying appropriate and necessary reasonable accommodations is completed.
  1. Once Dunkin & Bush receives a fully completed release and any requests for reasonable accommodation in the testing process are resolved, Dunkin & Bush will schedule candidates for the post-offer/pre-placement functional employment test.
  1. Upon reporting to the licensed WORKSTEPS testing facility, candidates will be examined by a licensed occupational or physical therapist and their staff.
  1. Candidates who successfully complete the post-offer/pre-placement functional employment test and satisfy all the other conditions of their offers of employment will be informed of a “start” date by a Dunkin & Bush authorized representative.
  1. Dunkin & Bush will notify candidates who are determined to be “not capable” of performing the essential functions of the job. Since Dunkin & Bush seeks to make employment decisions based on the best available objective medical evidence, candidates who receive a “not capable” result or who are unable to complete the test should provide Dunkin & Bush with any additional information they believe Dunkin & Bush should consider in evaluating the conditional offer of employment.
  1. Absent receipt of additional information that persuades Dunkin & Bush that a candidate can safely and successfully perform the essential functions of the position sought, Dunkin & Bush will not place candidates who fail to successfully complete the post-offer/pre-placement functional employment test. If the candidate has provided Dunkin & Bush with information documenting a disability, Dunkin & Bush will analyze the medical and functional data relating to the candidate’s functional abilities, limitations and work restrictions as such relate to the candidate’s capability to perform essential job functions, with or without a reasonable accommodation. If Dunkin & Bush determines that the candidate is not qualified to perform the essential job functions with or without a reasonable accommodation or the candidate would pose a direct threat to the health and safety of the candidate or others, which threat cannot be reduced to an acceptable level with a reasonable accommodation, Dunkin & Bush will withdraw the conditional offer of employment.
  1. Medical information collected in connection with the administration of the functional employment tests and any related requests for accommodation will be maintained in confidential files in accordance with requirements of the Americans with Disabilities Act (ADA), as amended, and Washington’s Law Against Discrimination. The information collected will not be used for any purpose inconsistent with federal and state employment laws.

Dunkin & Bush is an equal opportunity employer and does not discriminate against individuals on the basis of race, religion, national origin, sex, gender identity, sexual orientation, age, marital status, the presence of sensory, mental or physical disability, or honorably discharged veteran or military status, or any other basis protected by federal, state or local law.

Acknowledgment:

I have read the above policy, and I understand that if I am offered employment with Dunkin & Bush in a position covered by this policy, one of the conditions placed on the offer will be the successful completion of a post-offer/pre-placement functional employment test. I agree to comply with the above procedure and request that my application for employment be processed pursuant to this policy.

Applicant’s Printed NameApplicant’s SignatureDate

Company RepresentativeDate

DUNKIN & BUSH, INC.

Drug and Alcohol Testing

The use of illegal drugs, the abuse of prescription drugs, and the abuse of alcohol by its employees are of utmost concern to Dunkin & Bush, Inc. (the "Company"). A drug is “illegal” if it is considered a “controlled substance” under federal law and has not been prescribed to the employee by a physician. For example, marijuana and the cannabis plant are illegal drugs under federal law and this policy. Employees who use illegal drugs, abuse alcohol, or abuse prescription drugs are more likely to suffer industrial accidents, work at a less efficient rate, miss more time from work, and create an undue risk of harm to themselves, their co-workers, and the general public. For these reasons, the Company has implemented an extensive drug, alcohol, and firearms policy.

The manufacture, use, transfer, sale or possession of narcotics, drugs, or controlled substances or the consumption or being under the influence of alcoholic beverages or illegal drugs while on the job or on Company or customer property, other than the possession of drugs or controlled substances prescribed by a physician, are prohibited activities under this policy. The possession, transfer, and use of marijuana, which is a schedule I controlled substance under federal law, is expressly prohibited under this policy even if its medical or recreational use is authorized under state law.

All job offers are contingent upon passing a post-offer pre-employment drug test. The Company will test all applicants to whom a job offer is extended for illegal drugs, alcohol, and controlled substance use. All job applicants are required to consent to drug and alcohol testing. At the Company’s discretion, applicants who have received a contingent job offer will be requested to immediately submit a specimen for on-site testing or will be required to report to a collection facility within 24 hours of the Company’s request.

All applicants who test positive for the use of illegal drugs, alcohol, or controlled substances other than drugs legally prescribed by a physician will have their job offers withdrawn and will not be considered for employment with the Company at that time. An applicant who tests positive may reapply to the Company upon presenting proof of satisfactory completion of an assessment/rehabilitation program approved by the Company, and by signing a Last Chance Agreement. If the applicant tests positive on a second pre-employment test, he/she will be ineligible for employment and will be denied any further opportunity to reapply for at least one (1) year.

Results of an initial post-offer pre-employment urine screen ruled dilute by the testing laboratory, or by on-site technology used, by reason of low specific gravity or creatinine will be ruled inconclusive. A negative test result is required prior to employment. The applicant is entitled to submit to a second screen at his or her own expense within 24 hours or immediately where on-site collection is requested by the Company. If the applicant refuses, or if the second screen is confirmed dilute, the applicant will be denied employment with the Company at that time.

An applicant who fails to fully cooperate with collection site personnel, engages in any conduct which creates reason to believe a urine specimen has been altered, adulterated or substituted, fails to report to the collection site within the prescribed time, or produces a specimen that is out of normal temperature range, will not be considered for employment with the Company.

If the specimen is deemed inadequate for not meeting the minimum quantity requirements, the original insufficient specimen shall be discarded, and the applicant will be allowed up to 2 hours to attempt to provide a satisfactory specimen. If the applicant leaves the collection site or is still unable to provide an adequate specimen, the applicant will be denied employment with the Company.

Collection of urine, blood, hair, saliva and/or breath specimens for testing shall be conducted at a designated collection site. All test specimens shall be properly identified and handled with appropriate chain of custody procedures. An explanation of the chain of custody procedures utilized by the collection/testing facility will be made available to any applicant upon request.

In order to ensure fairness, the laboratory shall retain a sufficient portion of the urine specimen to be made available for conducting independent testing by a certified independent laboratory of the applicant’s own choosing, the cost of which shall be borne by the employee/applicant. A request for such independent testing must be made in writing within two (2) working days of being advised of the initial positive test results. If the re-test results prove negative, a second collection and test will be allowed. If the results of the second test of the initial specimen or the test of the second specimen prove positive, the applicant will be denied employment with the Company.