NOTICE TO ALL APPLICANTS: Marvin Windows and Doors has a drug testing policy that requires drug testing as part of the post-conditional offer process for all applicants extended a conditional offer of employment. Please complete this application in its entirety. Your opportunity for employment with Marvin Windows and Doors will depend upon the completeness and accuracy of information on this form. P.O. Box 100, Warroad, MN 56763 APPLICATION FOR EMPLOYMENT VEHICLE OPERATOR PLEASE PRINT PLAINLY Date Name Last First Middle Home No. ( ) Cell No. ( ) E-mail address: Previous addresses in the last (7) years beginning with present address: Mailing address Length of Time Previous address Length of Time Previous address Length of Time Previous address Length of Time Previous address Length of Time How did you learn about employment opportunities at Marvin Windows and Doors? Have you applied for employment at Marvin previously? Yes No If yes, when? Have you worked for us before? Yes No If yes, when? If hired, on what date will you be available to start work? If hired, can you furnish proof that you are 21 years of age or older? Yes No Date of Birth (Required for Commercial Driver) If hired, can you provide proof that you can legally work in the United States? Yes No
Education Type of School Name, City, State, and Zip Code Years Completed High School 9 10 11 12 Graduated Yes/No Major GPA College 1 2 3 4 Post Graduate 1 2 3 4 Business or Trade 1 2 3 4 Other GED References Name and Occupation Street Address, City, State, Zip Code Phone Number 1. 2. 3. Employment History All applicants to drive a commercial motor vehicle* in intrastate and/or interstate commerce must provide the following information on all employers during the preceding ten(10) years: (List employers in reverse order starting with the present or most recent) testing requirements of 49 CFR Part 40? Yes No testing requirements of 49 CFR Part 40? Yes No testing requirements of 49 CFR Part 40? Yes No
Prior Work History (List in order with present employer first) * Includes vehicle shaving GVWR of 26,001 lbs. or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding. ** The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle:(1) weighs or has GVWR of 10.001 pounds or more, (2) is designed or used to transport 9 or more passengers, OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
Violations: Provide a true and complete list of violations (other than parking violations)for which you have been convicted or forfeited bond or collateral during the past three (3) years. Date Offense Location Type of Vehicle Operated Check here if you have not been convicted forfeited bond or collateral on account of any violation required to be listed during the past three (3) years. Accident Record: Provide accident record for the past three (3) years or more (attach sheet if more space is needed): if none, write none. Dates Last Accident Nature of Accident (Head-on, Rear-end, Upset, etc.) Fatalities Injuries Hazardous Material Spill Licenses: List all driver licenses or permits held in the past three (3) years and, if applicable, any other unexpired driver licenses or permits. State License No. Type Expiration Date Driver Licenses A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No B. Has any license, permit or privilege to operate a motor vehicle ever been suspended or revoked? Yes No If the answer to either A or B is yes, give details: Please attach official copies (MVRs) of your driving record from the appropriate agencies of each state in which you have held a motor vehicle operator s license or permit for the last three (3) years. 19913899 2014-07-25
MARVIN-1~ Windows ;,nd Doors Built around you: Disclosure and Release of Information Authorization NOTE: The following information, which is required for pre-employment screening purposes, IS NOT considered as part ofyour application for employment. It is used ONLYfor identification purposes, verifying information and conducting a background check. PLEASE PRINT CLEARLY. Last Name First Name Street Address City Drivers License No. State of License Middle Name Date of Birth ZIP State Expires On List any other CITIES AND STATES in which you have lived or worked during the previous 7 years. List any other LAST NAMES you have used during the previous 7 years. List any other LAST NAMES under which you received your GED, high school diploma, or other degrees. I authorize Marvin Windows and Doors and Employment Screening Associates, a consumer reporting agency, to retrieve information from all personnel, educational institutions, government agencies, companies, corporations, credit reporting agencies, law enforcement agencies at the federal, state (including the Minnesota Bureau of Criminal Apprehension), or county level, or individuals, relating to my past activities, to supply any and all information concerning my background, and release the same from any liability resulting in providing such information. The information received may include, but is not limited to, academic, residential, achievement, job performance, attendance, litigation, personal history, credit reports, driving history, and criminal history records. If my prior employers and/or references are contacted, the report may include information obtained through personal interviews regarding my character, general reputation, personal characteristics and/or mode of living. If currently employed: My current employer may be contacted. YES NO I understand that a consumer report may be prepared summarizing this information, and I understand that my employment, promotion, or retention may be determined in whole or in part based on any consumer report or investigative consumer report generated by the consumer reporting agency identified above. I may request a copy of any report that is prepared regarding me and may also request the nature and substance of all information about me contained in the files of the consumer reporting agency. I understand that proper identification will be required and that I should direct my request to: Employment Screening Associates, 8040 Blue Ash Rd., Cincinnati, OH 45236. Phone: (800) 706-8848. I would like a copy of any report regarding me. YES NO I agree that a photocopy of this authorization may be accepted with the same authority as the original. I also agree that this release will remain in effect throughout my employment with Marvin Windows and Doors. Signature Social Security Number Date NOTARY. Currently required for Statewide Criminal Checks in AL, GA, NM, Rl, WV, and WY; sometimes required in MN depending on search. State Signature. County of My Commission Expires o n ' - - - - - - - - - - -
INFORMATION FOR APPLICANTS FOR DOT-COVERED POSITIONS MARVIN WINDOWS & DOORS Federal law requires applicants to indicate whether they have previously refused to be tested or received a positive test result on any pre-employment test for any other DOT employer. Please provide this information below. It is a federal offense to falsify this information. D I have NOT tested positive on a pre-employment drug test for any other DOT employer in the past three years, nor have I refused to be tested. (If so, please sign below, and complete the remainder of this form.) D Yes, I tested positive (or I refused to be tested) on a pre-employment drug test for another DOT employer in the past three years. (If so, please sign below, and do not continue.) However, if you have completed a SAP return-to-duty process, please provide us with contact information for your SAP, so that we can obtain copies of your paperwork. In this case, you can continue with our application process. Signature of Applicant Date Each applicant for a DOT-covered position at Marvin Windows & Doors, after being notified that he/she will be offered a job, must be drug tested, in accordance with federal regulations 49 CFR Part 382. If the test result is positive, or if the applicant refuses to submit to a preemployment test, the job offer will be withdrawn. We must have a negative test result in our file before we can request or allow an employee to perform safety-sensitive functions for us. The cost of the initial screening test and the confirmatory test will be paid by Marvin. Every applicant who provides a positive test result will have an opportunity to speak with a Medical Review Officer about any recent use of prescription and non-prescription drugs that might explain the positive test result. An applicant whose test result is positive may, within 72 hours, request a test of the split specimen, at his/her own expense. The test will be conducted on the split of the original sample, and mu st be conducted by a different DI-U-IS-certified testing laboratory. I have not tested positive (or refused to be tested) on a DOT pre-employment drug test, at any time in the previous three years. (If I have, I have also completed a SAP return-to-duty process.) My signature below means that I have read this information, that I have had an opportunity to review a copy of Marvin's drug and alcohol testing policy. and that if I am offered a position, I understand that I must be tested for drugs as a condition of employment. Signature of Applicant
Truck Driver Job Function Work as a truck driver generally involves physical activities such as: sitting 80% of the time; performing repetitive hand, wrist and arm motions; lifting, pulling or pushing up to 80 pounds unassisted frequently, and up to 300 pounds with assistance frequently; bending, stooping, twisting and turning; climbing stairs, ladders and working in elevated areas; and standing on concrete for 10 hours while working in the plant. Are you able to perform the essential functions of the job (as described above) with or without reasonable accommodation? Yes No Section 391.41 of the Federal Motor Carrier Regulations states that a person shall not drive a motor vehicle unless he/she is physically qualified to do so. Experience and Qualifications CLASS OF EQUIPMENT CIRCLE TYPE OF EQUIPMENT Straight Truck Yes No (Van, Tank, Flat, Dump, Refer) Tractor and Semi-Trailer Yes No (Van, Tank, Flat, Dump, Refer) Tractor - Two Trailers Yes No (Van, Tank, Flat, Dump, Refer) Tractor - Three Trailers Yes No (Van, Tank, Flat, Dump, Refer) Motorcoach - School Bus (more than 15 passengers) Yes No Other - - DATES FROM (M/Y) TO (M/Y) APPPROX. NO. OF MILES (TOTAL) List states operated in for the last five (5) years: List any experiences in operating a motor vehicle, including the type of vehicle, that are not listed elsewhere in this application: Which safe driving awards do you hold and from whom? Loading Dock - List type of loading dock experience and length of experience: List platform equipment you can operate (lift trucks,etc.): Truck Maintenance - List type of truck maintenance and length of experience: Training - List courses and training other than shown else where in this application: List special equipment or technical materials you can work with (other than those already shown): If you first began operating a commercial motor vehicle after, July 20, 2003 have you received a training certificate or diploma certifying compliance with the FMCSR, and in particular,49 CFR 380.5 13? Yes No
Use the space below to provide any additional information. Applicant s Certification and Acknowledgment I certify that the information contained in this application is true and complete to the best of my knowledge. I understand that any false statement, intentional omission or misrepresentation on this application or at any time in the hiring process is sufficient cause for refusal to hire, or dismissal if I have been employed, no matter when discovered by Marvin Windows and Doors. I hereby authorize Marvin Windows and Doors and its agents, to the extent permitted by law, to investigate all statements contained in my application, resume, and otherwise provided during the hiring process and to solicit information regarding my current and former employment, education, character, and general reputation. I authorize my current and former employers, references, and relevant parties to disclose such information to Marvin Windows and Doors, and I voluntarily and knowingly fully release and hold harmless any person or organization that provides such information from any and all claims, demands, or liabilities arising out of or related to the investigation, disclosure, or use of such information. I hereby authorize Marvin Windows and Doors to seek information about my alcohol and controlled substance history and safety performance history as required by 40 CFR 391.23(d) and (e). I understand that I have the right to review information by previous employers, have errors in the information corrected by previous employers and to re-send the corrected information to the prospective employer, and to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and I cannot agree on the accuracy of the information. I understand and agree that nothing obtained in this application, or conveyed during any interview, is intended to create a contract, offer, or promise of employment. I further understand and agree that if I am hired, my employment will be at will and without fixed term, and may be terminated at any time, with or without prior notice, at the option of either myself or Marvin Windows and Doors. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon Marvin Windows and Doors unless made in writing by an authorized Marvin Windows and Doors officer or official. I understand that, should I receive a conditional employment offer, such offer may be conditioned on my successful completion of a background check, credit check, physical examination, and/or alcohol and drug screening, as permitted by local, state, and federal law. I consent to such inquiries, examinations, and tests, and I request the results of such tests and examinations to be disclosed to Marvin Windows and Doors, as permitted by law. I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States. I agree that if employed, I will abide by all Marvin Windows and Doors work rules, policies, and procedures. I understand that Marvin Windows and Doors reserves the right to revise its policies or procedures, in whole or in part, at any time, with or without notice. By my continued employment, I consent to any changes. I certify and acknowledge that I have read, fully understand, and accept the above statements and terms. This application was completed by me, and all entries on it and information in it are true and complete to the best of my knowledge. Signature of Applicant Date Marvin Windows and Doors is an Equal Opportunity Employer and does not discriminate in recruitment, hiring, training, promotion, or other employment practices because of race, color, creed, religion, national origin, sex, marital status, sexual orientation, age, disability, protected veteran or military status, status with regard to public assistance, genetic information, or any other status protected by applicable federal, state, or local law. Marvin Windows and Doors will make reasonable accommodations to the known qualifying disabilities of applicants and employees when doing so will not impose an undue hardship. Applicants who believe they may need reasonable accommodation to enable them to participate in the application process should contact Human Resources. 19913899 2014-07-25