Former Employer Permission

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					                              Employment Application Cover Sheet

Diversified Industrial Services is committed to providing equal opportunity for all individuals who are
seeking employment. We are dedicated to a policy of non-discrimination in employment on any basis
including race, color, religion, creed, national origin, sex, age, marital status, disabled veteran, Vietnam-
era veteran, disability or sexual orientation. the objective of Diversified Industrial Services' hiring
procedure is to select the most qualified individual for the job.

An applicant who needs reasonable accommodation to assist in any step of the hiring process should
contact the Human Resources Office @ (425) 355-1253.

In submitting this application for employment I understand that Diversified Industrial Services will
investigate the information that I provide. If you are selected for an interview then you will need to
provide Diversified Industrial Services with a release and waiver form so that we may obtain a
background check and a drug test. All drug test data will be maintained as a confidential record.

I understand that I also must complete an I-9 form and provide legal documents showing I am
authorized to work in the United States. If you report false, inaccurate or misleading information, we
will reject your application or terminate your employment if we discover such information after the date
of hiring.

I understand that federal law imposes imprisonment and/or fines upon any person who makes a false
statement, uses a document issued to someone else, or uses a counterfeit, altered, forged or falsely made
document to obtain employment.

I have read and understand all of the instructions and acknowledgements set forth above. My signature
represents that I will comply and that I understand the consequences if I do not comply.




                        Applicant's Printed Name




                          Applicant's Signature                                            Date
                                                                                              Revised 06/30/2008
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Employment Application


Position Applied for:                                                                               Desired Wage:

APPLICANT INFORMATION
Last Name                                              First Name                                              M. I.        Date


Street Address                                                                                                              Apartment/Unit #


City                                                                State                                                   Zip Code


Home Phone                                Cell/Contact Phone                       E-Mail Address



Are you a citizen of the United States?    Yes   q      No     q      If no, are you authorized to work in the U.S.?         Yes     q       No   q
Have you ever worked for this company?     Yes   q      No     q      If so, when?

Have you ever been convicted of a crime? Yes     q      No     q      If yes, explain.

How did you hear about us?


EDUCATION
High School                                                         Address


From                         To
                                                               Did you graduate?     Yes   q        No   q     Degree

College                                                             Address


From                         To
                                                               Did you graduate?     Yes   q        No   q     Degree

Other                                                               Address


From                         To
                                                               Did you graduate?     Yes   q        No   q     Degree


REFERENCES (Please list three professional references)
Full Name                                                                                       Relationship/Title


Company                                                                                                        Phone (include area code)


Address


Full Name                                                                                       Relationship/Title


Company                                                                                                        Phone (include area code)


Address


Full Name                                                                                       Relationship/Title


Company                                                                                                        Phone (include area code)


Address




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PREVIOUS EMPLOYMENT
Company                                                                                                             Phone (include area code)


Street Address                                                                                                      Supervisor


Job Title                                                                                             Starting Salary              Ending Salary
                                                                                                      $                            $
Responsibilities


From                         To                           Reason for Leaving



May we contact your previous supervisor for a reference?                  Yes    q       No    q
Company                                                                                                             Phone (include area code)


Street Address                                                                                                      Supervisor


Job Title                                                                                             Starting Salary              Ending Salary
                                                                                                      $                            $
Responsibilities


From                         To                           Reason for Leaving



May we contact your previous supervisor for a reference?                  Yes    q       No    q
Company                                                                                                             Phone (include area code)


Street Address                                                                                                      Supervisor


Job Title                                                                                             Starting Salary              Ending Salary
                                                                                                      $                            $
Responsibilities


From                         To                           Reason for Leaving



May we contact your previous supervisor for a reference?                  Yes    q       No    q
MILITARY SERVICE
Branch                                                                                                From                         To



Rank at Discharge                                                                      Type of Discharge

If other than honorable, explain:

DRUG TEST
Would you be willing to take a drug test?                  Yes    q       No    q      Diversified Industrial Services is a drug-free environment.

DISCLAIMER AND SIGNATURE
I certify that my answers are true and complete to the best of my knowledge. I authorize Diversified Industrial Services to run a background investigation if I
am being seriously considered for employment. If this application leads to employment, I understand that false or misleading information in my application
or interview may result in my release.
Signature                                                                                                           Date




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                     Affirmative Action Information Form

              COMPLETION OF INFORMATION BELOW IS VOLUNTARY


Diversified Industrial Services is an equal opportunity employer, dedicated to a policy
of non-discrimination in employment including race, color, creed, national origin, sex,
age, marital status, disabled veteran, Vietnam-era veteran, disability or sexual
orientation. Consistent with the American with Disabilities Act, applicants may request
accommodations needed to participate in the application process.

* This form is to be completed by applicant on a VOLUNTARY BASIS.


* The information on this form is not to be used for interview purposes.


* This form is to be filed separately from the application form(s).


      q     I volunteer to provide the following information          q     I DO NOT wish to participate



Name:                                                                          Date:


Position(s) being applied for:


Referral Source:

      q     Male                                  q    Native American Indian
      q     Female                                q    Asian / South Sea Islander
                                                  q    Black
      q     Vietnam-era veteran                   q    Hispanic
      q     Disabled veteran                      q    White (not of Hispanic origin)
      q     Disabled                              q    Other
                                                        (please specify):

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                   Pre-Employment Drug Testing Consent Form


Applicant's Printed Name




Social Security Number



I understand that all applicants who are being considered for employment with Diversified Industrial
Services are required, as a condition of employment, to take a drug-screening test. I understand that any
applicant who refuses to take, alters, tampers with or contaminates any drug test will be dropped from
further employment consideration.


I hereby consent for Diversified Industrial Services or its agents to collect a urine specimen and to conduct
urinalysis testing to determine the presence of drugs or controlled substances. I authorize release of my test
results to the appropriate representative of Diversified Industrial Services.

I understand that any candidate who fails a drug test will be dropped from further employment consideration
and may not re-apply for employment for at least 6 months.




                     Applicant's Signature                                            Date

Please complete section below:
  Subject Information

Applicant's Name                                         Social Security Number                  Date of Birth




Alias/Maiden Name                               Sex             Race              Drivers Lic # / State




  4b7bd766-70ee-405b-bf53-7a257b460410.xls        Page 5 of 7                                         Revised 06/30/2008
           EMPLOYER REFERENCE RELEASE


I, ________________________________________, release all former employers listed on any
application and/or resumes from any and all liabilities in giving any references on my previous work
history. Information may include job performance, duties performed, attendance practices or any other
information that a former employer may feel helpful to Diversified Industrial Services in efforts to hire a
qualified person.




                  Applicant's Printed Name




                    Applicant's Signature                                     Date




                                                                                            Revised 06/30/2008
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           Permission for Comprehensive Background Check of Prospective Employee
        In connection with my application for employment with Diversified, I hereby agree as follows:
    1. General Consent to Background Investigation
           As a condition of Diversified's consideration of my employment application, I give permission to
        Diversified to investigate my personal and employment history. I understand that this background
        investigation will include, but not be limited to, verification of all information on my employment
        application.
    2. Consent to Contact Past Employers
           I specifically give permission to Diversified to contact all of my prior employers for references. I
        further give permission to all current or previous employers and/or managers or supervisors to discuss
        my relevant personal and employment history with Diversified, consent to the release of such
        information orally or in writing, and hereby release them from all liability and agree not to sue them
        defamation or other claims based upon any statements they make to any representative of Diversified. I
        further waive all rights I may have under law to receive a copy of any written statement provided by any
        of my former employers to Diversified. I further agree to indemnify all past employers for any liability
        they may incur because of their reliance upon this Agreement.
    3. Consent to Contact Government Agencies
            I further give permission to Diversified to receive a copy of any information obtained from the file of
        any federal, state, or local court, or governmental agency concerning or relating to me. I further consent
        to the release of such information and waive any right under law concerning notification of the request
        for a release of such information. In the event a law does not provide for prospective employers to have
        access to information, I hereby delegate Diversified as my agent for the receipt of information. I
        understand that the scope of this investigation will be limited as required by applicable law.
    4. Cooperation with Investigation
           I agree to fully cooperate in Diversified's background investigation, and to sign any waivers or
        releases that may be necessary or desirable to obtain access to relevant information. In the event that
        any former employer or federal, state, or local governmental agency will not release reference
        information or criminal history information directly to Diversified, I agree to personally request such
        information to the extent permitted by law,
    5. Miscellaneous
           This Agreement represents the entire understanding and agreement relating to its subject matter.
        Diversified shall be entitled to fully rely on this Agreement. I understand that I have no guarantee of
        employment and that Diversified may determine not to hire me for any lawful reason.


        Applicant's Printed Name



        Applicant's Signature                                           Date

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