Laborers� International Union of North America

							           Laborers’ International Union of North America
                                       Application
                                    5806 Meredith Dr.      Phone No. 515-270-6961

                                   Des Moines, IA 50322

Name ____________________________________           Social Security No. __________________

Address __________________________________          Mobil Phone No. ( )________________

City/State _________________________________ Zip Code _________________________

E – Mail Address ________________________@____________________________________

Are you willing to take a Pre-Employment Drug Screen?     YES ____ NO ____

Are you 18 years of age or older? YES ____ NO ____

Do you have a Valid Driver License? YES ____ NO ____

How many miles from home are you willing to Travel? 25___ 50___ 75___ 100___

Do you have any health problems or Injuries that could affect your Employment?

YES ____ NO ____ If Yes, Please Explain __________________________________________

Do you have any prior Mason Tending Experience? YES ____ NO ____

If Yes, List the Names and Addresses of Contractors you worked for _______________________

___________________________________________________________________________

Do you have any prior Laborers’ Experience? YES ____ NO ____

If Yes, List the Names and Addresses of Contractors you worked for _______________________

___________________________________________________________________________

Circle Last Grade Completed 8 9 10 11 12 More than 12

Are you a High School Graduate/G.E.D.? YES ____ NO ____        Year of Graduation _________

Do you have a College Degree? YES ____ NO ____                Year of Graduation _________
List your Last Three Employer                                    Date of Employment

1. ____________________________________                          ___________________

2. ____________________________________                          ___________________

3. ____________________________________                          ___________________

I am a Citizen, National or Authorized Alien of THE UNITED STATES, YES ____ NO ____

Are you a U.S. VETERAN? YES ____ NO ____         If Yes, Entry Date ___ /___ /______

Branch of Service ___________ M.O.S. __________ Type of Discharge ______________

Are you willing to adhere to the Following Work Principles?

1. Attend All required Training Classes during your Apprenticeship and Journeymen Upgrading.

2. Report to Work on All Scheduled Days.

3. Report to Work on Time and be prepared to perform the duties assigned to you daily.

4. Take a Pre-hire Drug Screen and be willing to take Random Drug Screens if asked.

5. Not abuse Breaks or Lunch Periods.

6. GIVE 8 HOURS WORK FOR 8 HOURS PAY.

7. NEVER QUIT A JOB TO WHICH YOU HAVE BEEN REFERRED.

8. Travel to a Job within the State Of IOWA.

                                      YES ____ NO ____

I UNDERSTAND THAT MY PAY RATE AS ESTABLISHED BY THE UNION WILL BE DETERMINED BY
MY LEVEL OF QUALIFICATIONS AND TRAINING.

           SIGNATURE _________________________ DATE___________________

I ATTEST THAT THE INFORMATION I HAVE GIVEN IS GENUINE AND TRUTHFULL.

          SIGNATURE _________________________ DATE ___________________