APPLICATION FOR EMPLOYMENT 2600 Kindustry Park Road – Keokuk, IA 52632 – Phone 319-526-0210 -- Fax 319-526-0216 Ziegler Industries, Inc. is an Equal Opportunity Employer. It is our policy to provide equal opportunity in all areas of employment practice and to assure that there shall be no discrimination against any employee or applicant for employment because of race, color, religion, sex, creed, national origin, age, disability, marital status, sexual orientation, gender identity or any other characteristic protected by law. PERSONAL INFORMATION First Name (required) Middle Initial Last Name (required) Street Address (required) City (required) State (required) Zip (required) How many years at this address? (required) Previous Address City State Zip How many years at this address? Home Phone: (required) Alternate Phone: What is your email address? (required) Are you 18 years or older? YesNo Are you legally eligible for employment in the U.S.? YesNo POSITION APPLYING FOR Position Applied for (required) Full TimePart TimeTemporary How did you hear about this position? Date Available to Begin Work: Hourly Rate/Salary Required: Which shifts are you willing to work? (required) WeekdaysWeekendsEveningsOvertimeShiftOther Have you applied at Ziegler Industries, Inc. before? YesNo If yes, when?: Were you interviewed? YesNo Do you have any relatives/friends employed at Ziegler Industries, Inc.? YesNo If yes, please list name(s) and Relationship: On occasion, overtime hours may be required. Would you work overtime if asked? YesNo ADDITIONAL INFORMATION If the position you are seeking involves travel in a personal or company vehicle, please indicate the following: Current Driver's License Number States in which you have held a driver's license: EDUCATION High School School name & Address: Did you graduate? YesNoGED Major or Courses of Study: Post High School School name & Address: Did you graduate? YesNo Major or Courses of Study: EMPLOYMENT HISTORY Please attach your resume: Acceptable file types: .txt .doc .docx .pdf FIELD EQUIPMENT OPERATION/FIELD SKILLS Skills (Years) Conventional Painting Airless Painting Abrasive Blasting Blast Tracking Rigging for Containment Scaffolding Erection Fireproofing Plural Component Ultra High Water Jetting Floor Coatings Maximum Height able to work at Ladders and scaffolding Other (list): Experience (Years) Airless Paint Pump Conventional Paint Pot Bulk Blast Pot 6-8 Ton Blast Pot 300-600 lb Ultra High Water Jetting Spider Basket DH Equipment Dust Collection Equipment Compressors Other (list): QA/QC Experience (Years) 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): Training/Special Certifications (Level) NACE SSPC First Aid/CPR CDL Lead Forklift Scaffolding QA/QC Supervisor Hazardous Waste TWIC Other (list): AUTHORIZATION: Please read and understand this statement before submitting your application: I certify that the facts contained in this application are true and complete to the best of my knowledge. I further understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein. I release from any and all liability all the references and employers listed above who provide information concerning my previous employment and any other information, personal or otherwise, to Ziegler Industries, Inc. This application will expire in 60 days. After that date, I understand that my status as an applicant will end. I may re-apply for employment in the future by completing a new application. This application is not an employment agreement. If I accept an offer of employment I understand the employer may terminate my employment at any time, with or without cause and without prior notice, unless required by law. I understand that no one, other than one of the employer Partners, has the authority to enter into any employment agreement with terms contrary to the foregoing and then only in writing signed by such officer. Ziegler Industries, Inc., in considering my application for employment may verify the information set forth on this application and obtain additional background information relating to my background. I authorize all persons, schools, companies, corporations, and law enforcement agencies to supply any information concerning my background. I understand that Ziegler Industries, Inc. has a commitment to maintain an alcohol/drug-free workplace and that Ziegler Industries, Inc., unless prohibited by state law, requires a drug screening test as a part of its selection and hiring process. I understand that such drug screening will consist of the testing of a urine sample or other medically recognized test designed to detect traceable amounts of a controlled substance in my body. If after a second confirmatory test it is determined my specimen contains a controlled substance or was altered or substituted, I will be disqualified from consideration for employment and any offer of employment will be withdrawn. I further understand and agree that if I am employed, I may be required to submit to drug-testing under certain circumstances during my employment. I understand that after an offer of employment, and prior to reporting to work, I am required to submit to a medical review. Depending on company policy and the essential functions of the job, I will be required to complete a medical history form and may be required to be examined by a medical professional designated by Ziegler Industries, Inc. I fully understand and accept all terms and conditions in the above statement.