Employment Opportunities at Northern Dewatering

PERSONAL INFORMATION

First Name

Middle Name

Last Name

Street

City

State

Zipcode

Social Security Number (LAST 4)

Home Phone

- -

Cell Phone

- -

Email

Is Your Age Under 18? If yes, what is your birth date?

Yes No

In case of emergency notify:

Date of Birth

EDUCATION AND TRAINING

High School

College: Name/Location/Degrees

Other: Name/Location/Degrees

EMPLOYMENT INFORMATION

Position Desired:

Are you presently employed?

Yes No

May we contact your present employer?

Yes No

If No, Please State Reason:

Have you been previously employed by Northern Dewatering?

Yes No

What date would you be available for work?

EMPLOYMENT HISTORY

LIST LAST FOUR EMPLOYERS BEGINNING WITH THE MOST RECENT. PREVIOUS EMPLOYERS MAY BE CONTACTED.

1) Name, Address & Phone Number of Employer

Month and Year

Supervisor and Position held

Reason for Leaving (required)

2) Name, Address & Phone Number of Employer

Month and Year

Supervisor and Position held

Reason for Leaving (required)

3) Name, Address & Phone Number of Employer

Month and Year

Supervisor and Position held

Reason for Leaving (required)

4) Name, Address & Phone Number of Employer

Month and Year

Supervisor and Position held

Reason for Leaving (required)

Drivers License

Yes No

State and License Number

Commercial Drivers License (C.D.L)

Yes No

If yes, Classifications

Please state any restrictions on your drivers license

EQUIPMENT EXPERIENCE -- LIST EQUIPMENT YOU CAN OPERATE

Equipment, Month, Years, Experience, Where/for Whom

PHYSICAL REQUIREMENTS FOR ESSENTIAL OCCUPATIONAL FUNCTIONS The applicant acknowledges that the following physical requirements for a construction employee employed by Northern Dewatering, Inc. (NDI) which the applicant is making this application for are as follows:

1. PHYSICAL LIFTING REQUIREMENTS

The employee must be able to regularly(12 times per hour, 8 hours per day) lift up to 60 pounds and carry such weight throughout a construction site. On several occasions throughout the workday (1 to 2 times per hour, 8 hours per day) the employee must be able to lift and carry up to 75 pounds. Approximately 3 times per 8 hour day, the employee must be able to lift and carry up to 100 pounds.

2. PHYSICAL FUNCTIONAL REQUIREMENTS
Construction work performed by employees of NDI is strenuous and requires much physical exertion, including but not limited to:

Stooping and bending -- also lifting while stooping and bending.
Crawling on hands and knees.
Reaching out and overhead -- also lifting while reaching out and overhead.
Climbing stairs and ladders. Also climbing on uneven grounds and into and out of excavations. Also climbing on equipment.
Twisting at the waist and neck.
Balancing and carrying material and equipment.
Waking on even and uneven, rough ground.
Shoveling and raking rocks, dirt, sand or concrete.

3. PHYSICAL ENVIRONMENTAL REQUIREMENTS

Construction work performed by employees of NDI is generally performed outdoors in all types of weather conditions typical to the Midwest.

Employees must be able to withstand and perform in extreme temperatures (-10° to +100°) rain, snow, sleet, wind and other inclement weather conditions.

Are you able to perform the above requirements with or without an accommodation?

Yes No

If an accommodation is needed, how would you perform the requirement, and with what accommodation?

I acknowledge that I have received a copy of the NDI Employee Handbook and I am responsible for reading and being aware of the contents. I acknowledge that it is my responsibility to abide by all company rules and regulations as set forth in the Employee Handbook and/or rules or regulations that NDI may otherwise establish. I understand that the contents of the Employee handbook, and other rules and regulations, may be changed by NDI at any time, with or without notice.

I further understand that employment at NDI is at-will and neither the policies described in the NDI Employee Handbook nor any other verbal or written representations made by management representatives are to be interpreted as a contract between NDI and myself. I understand and acknowledge that my employment can be terminated at the option of either NDI or myself, at any time, for any reason.

READ CAREFULLY AND SIGN

"I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND UNDERSTANDING AND THAT, IF EMPLOYED, FALSIFIED STATEMENTS ON THIS CONSIDERATION SHALL BE GROUNDS FOR DISMISSAL. I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY HAVE PERSONAL OF OTHERWISE,
AND RELEASE ALL PARTIES FROM ALL LABILITY FOR ANY DAMAGE THAT MAY RESULT FROM FURNISHING SAME TO YOU. I AGREE TO SUBMIT TO PRE-EMPLOYMENT, REASONABLE SUSPICION, POST ACCIDENT, PERIODIC, AND RANDOM, UNANNOUNCED DRUG AND/ OR ALCOHOL TESTING. TESTING MAY BE CONDUCTED WITH A BREATH TEST, URINE TEST OR BLOOD TEST. I AGREE TO BE TESTED AS PART OF NDl'S DRUG AND ALCOHOL FREE WORK SITE PROGRAM.

I UNDERSTAND I MAY BE REQUIRED TO COMPLETE A POST-OFFER FUNCTIONAL CAPACITY EXAMINATION AS A CONDITION OF EMPLOYMENT."

By typing the date and your name below is an authorized signature.

Date

Signature

Draw It
Clear

If selected for employment, are you willing to submit to a pre-employment drug screening test?

Equal Employment Opportunity Data

Various state and federal government agencies require employees to maintain the following information for job applicants and employees. However, you are not required to provide any of this information. Your submission of the information is completely voluntary. If you do provide the following information, this page will be separate from your application and/or personnel file, and placed in a confidential file. This information will not be used in any way in making employment decisions.

First Name

Middle Name

Last Name

Sex

Male Female I do not wish to disclose

Project #

How were you referred to Northern Dewatering?

Race/Ethnicity (Please check):

White (not of Hispanic or Latino) -A person having origins in any of the original peoples of Europe, North Africa, or the Middle East

American Indian or Alaska Native (not of Hispanic or Latino) -A person having origins in any of the original peoples of North and South America (including Central America), and who maintain cultural identification through tribal affiliation or community recognition

Black or African American (not of Hispanic or Latino) -A person having origins in any of the black racial groups of Africa

Hispanic or Latino -A person of Mexico, Puerto Rico, Cuba, Central or South America, or other Spanish culture or origin, regardless of race

Native Hawaiian or Other Pacific Islander (not of Hispanic or Latino) -A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or the Pacific Islands

Asian (not of Hispanic or Latino) -A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent; this includes Cambodia, China, India, Japan, Korea, Malasia, Pakistan, the Philippine Islands, Thailand, and Vietnam

Two or More Races (not of Hispanic or Latino Origin)

Government Contractors must take Affirmative Action to employ and advance certain qualified individuals subject to the Rehabilitation Act of 1973 and the Vietnam Era Veterans Readjustment Act of 197 4. Completion of the following information is voluntary and will be kept confidential separate from your personnel file. Failure to provide this information will not subject any employee or applicant to any adverse treatment and will be kept in accordance with the Federal Regulations governing this Program.

Please check where applicable

VETS 100 REPORTING:

Veteran of the Vietnam Era

Special Disabled Veteran

Other Protected Veteran

Recently-Separated Veteran (within 12 months of release from active duty)

VETS 100 A REPORTING:

Disabled Veteran

Armed Forces Service Medal Veteran

Recently-Separated Veteran (within 36 months of release from active duty)

*In the event you believe there is reasonable accommodation that will assist you in performing the essential functions of a job, please contact the Human Resources Department.

I understand that the disclosure of this information is for government reporting only, and will have no effect on the status of employment with Northern Dewatering, Inc.

First Name

Last Name

Signature

Draw It
Clear

Date

Social Security Number (LAST 4)

SUBMIT EMPLOYMENT FORM

Contact Us Today

(763) 428-2616

14405 Northdale Blvd

Rogers, MN 55374

Application for Employment

Employment Form

Apply for positions at Northern Dewatering using our online application