Job Application

PERSONAL INFORMATION
Today's Date*
Date Format: MM slash DD slash YYYY
Name (First, Last, MI)*
Other Names Used (First, Last, MI)*
Address*
Street Address Address Line 2 City State ZIP Code
Phone
Mobile Phone*

EMPLOYMENT HISTORY
Please list all employment, beginning with present or most recent employer. All information must be completed. Please also upload a file of your resume, if you have one.
Please Upload Your Resume, If You Have One
Employer Name (Most Recent)
Phone
Location
City State
Job Title
Job Hire Date
Date Format: MM slash DD slash YYYY
Job End Date
Date Format: MM slash DD slash YYYY
Name of Supervisor (First/Last)
Job Duties
Please list all job duties in a list format
Reason For Leaving
Employer Name #2
Phone
Location
City State
Job Title
Job Hire Date
Date Format: MM slash DD slash YYYY
Job End Date
Date Format: MM slash DD slash YYYY
Name of Supervisor (First/Last)
Job Duties
Please list all job duties in a list format
Reason For Leaving
Employer Name #3
Phone
Location
City State
Job Title
Job Hire Date
Date Format: MM slash DD slash YYYY
Job End Date
Date Format: MM slash DD slash YYYY
Name of Supervisor (First/Last)
Job Duties
Please list all job duties in a list format
Reason for leaving
Have you ever been suspended or discharged by any employer for misconduct, poor performance, absenteeism, or tardiness in the last seven years?
- Yes
- No
If yes, please explain the circumstances surrounding the discharge and the approximate date:

EDUCATION
Name of high school
Location
City State
Did you graduate?
- Yes
- No
Year graduated
Name of College, if any
Location
City State
Did you graduate?
- Yes
- No
Year graduated
Subjects studied
Name of Technical or Trade School(s), if any
Location
City State
Year graduated
Did you graduate?
- Yes
- No
Subjects studied
Please tell us about any other training or certifications you have

DRIVER'S LICENSE INFORMATION
Please provide information on any driver's licenses you've held within the last three years:
State*
License no.*
Class*
State
License no.
Class
State
License no.
Class

OTHER INFO
Do you have any physical conditions which may limit your ability to perform the job applied for?*
- Yes
- No
If yes, what can be done to accommodate your limitations?*
EMERGENCY CONTACT INFO
Please provide information for emergency contacts during work hours:
Name (first/last)
Relationship
Phone
Name (first/last)
Relationship
Phone
It is the policy of Robar Enterprises, Inc., Daily Transit Mix, LLC and AgCon, Inc. to afford equal opportunity for employment training, compensation and promotion to all individuals without regard to race, color, creed, religion, sex (including gender harassment and harassment based on pregnancy, childbirth or related medical condition), age, disability, sexual orientation, veteran status, or any other consideration made unlawful by federal, state or local laws.

PRE-EMPLOYMENT DRUG TESTING POLICY
As a component of the screening process, applicants shall be required to undergo drug and/or alcohol screening. Refusal or failure to submit to drug and/or alcohol screening at the time specified will disqualify applicants for further consideration for employment.

I voluntarily agree to submit to drug and/or alcohol screening as part of my application for employment.
Date*
Date Format: MM slash DD slash YYYY
Signature of applicant*

APPLICANT'S STATEMENT
I certify that the information I have given on this application is true and complete. I understand that omissions, misrepresentations, or falsifications of information will result in rejection of this application and/or will be sufficient grounds for immediate termination.

I authorize the release of all high school, college and other educational records pertaining to my attendance, course work and other school activities at any educational institute attended by me at any time.

I acknowledge by my signature that my former employer is released from any and all claims, demands or liabilities arising out of or in any way related to the disclosure of any and all information relating to my present and former employment, and I request all current and former employees to supply such information to Robar Enterprises, Inc., Daily Transit Mix, LLC and/or AgCon, Inc. upon its request. Additionally I waive and release Robar Enterprises, Inc., Daily Transit Mix, LLC and/or AgCon, Inc. and its agents from any liability for any action taken due to information provided by any current or former employer.

I agree that, if hired, I will conform to all rules, regulations and procedures of Robar Enterprises, Inc., Daily Transit Mix, LLC and/or AgCon, Inc. I further understand and agree that if I am hired, my employment with Robar Enterprises, Inc., Daily Transit Mix, LLC and or/AgCon, Inc. is for an indefinite period and may, regardless of the time and manner of payment of my wages and salary, be terminated at any time by Robar Enterprises, Inc., Daily Transit Mix, LLC and/or AgCon, Inc. or me, with or without prior notice or warning.

I further understand that this Application for Employment and any policies and procedures communicated or followed by Robar Enterprises, Inc., Daily Transit Mix, LLC and/or AgCon, Inc. during the term of my employment are not intended to be and are not a contract of employment, and that any such policies and procedures any be modified, disregarded or eliminated at any time, with or without notice to me, at the Company's sole discretion.

I understand that this application for employment shall be considered active for a period of time not to exceed 90 days from this date and that if I wish to be considered for employment. Beyond that date, I must submit another employment application.
Date*
Date Format: MM slash DD slash YYYY
Signature of applicant*

DISCLOSURE AND AUTHORIZATION
Notice Regarding Background Information

Notice is hereby given that Robar Enterprises, Inc. ("Company'') intends to request Mobile Occupational Services, Inc. ("MOS"), an Investigative Consumer Reporting Agency, to obtain information about you in the course of the Company’s consideration of your application for employment, promotion, reassignment or retention. Thus, you may be the subject of a consumer report/ investigative consumer report as defined by the FCRA/ICRAA. These investigative reports include information about one's character, general reputation, personal characteristics, and mode of living. This report is compiled through the following sources: education verification, license verification, names and dates of previous/current employment, work experience, work habits, work performance, workers compensation claims, criminal history, sex offender’s lists, wants and warrants records, motor vehicle records, and military records. The information contained in an investigative consumer report will be obtained from private and/or public record sources, including sources identified by you or through interviews or correspondence with your past or present coworkers, neighbors, friends, associates, current or former employers, educational institutions or other acquaintances. Reports may be obtained at any time after receipt of authorization and may be updated periodically if you remain an employee of the Company, as permitted by law.

The nature and scope of any investigative consumer report that may be requested is explained above. You have the right upon written request, made within a reasonable time after receipt of this notice, to request more information about the nature and scope by contacting the following: Mobile Occupational Services, Inc., 11687 Hesperia Rd., Hesperia, CA 92345, 760-244-6886, 800-429-9333, or by fax to 760-244-6061.

Additional State Law Notices

If you live or are applying for a job in the state of California, Maine, or New York, please review these notices:

CALIFORNIA: Mobile Occupational Services, Inc. (MOS) will provide you with a copy of an investigative consumer report when required to do so under California law. When you provide proper identification you may view Mobile Occupational Services, Inc.'s file maintained on you by any of the following methods: by appearing in person at Mobile Occupational Services, Inc.'s office during normal business hours with reasonable notice, via telephone (upon receiving a written request for telephone disclosure) , or by a requesting a copy by certified mail (MOS will not be liable for disclosures to third parties caused by mishandling of mail). If you appear in person, one other person may accompany you, provided that person furnishes proper identification.

MAINE: You have the right upon request, to be informed of whether an investigative consumer report was requested. If a report was requested, you may be informed of the name and address of the consumer reporting agency furnishing the report. You may request and receive from the Company, within five business days of our receipt of your request, the name, address, and telephone number of the nearest unit designated to handle inquiries for the consumer-reporting agency issuing an investigative consumer report concerning you. You also have the right, under Maine law, to request and properly receive from all such consumer reporting agencies copies of any such investigative consumer reports.

NEW YORK: You have the right, upon written request, to be informed of whether or not an investigative consumer report was requested. If a consumer report is requested, you will be provided with the name and address of the consumer reporting agency furnishing the report. You may inspect and receive a copy of the report by contacting that agency.

Authorization

I acknowledge that l have carefully read and understand this Disclosure and Authorization form. By my signature below, l authorize the obtaining of consumer reports and/or investigative consumer reports prepared by Mobile Occupational Services, Inc. and its agents, to the Company. I understand my consent will apply now as well as throughout my employment with the Company, to the extent permitted by law. To this end, l hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university, information service bureau, employer, and reference, to furnish any and all background information sought by Company or by Mobile Occupational Services, Inc., acting on Company's behalf. I agree that a facsimile ("fax") or photocopy of this Authorization shall be as valid as the original.

California. Minnesota, and Oklahoma applicants or residents: Please check the box below if you would like to receive a copy of your consumer report or investigative consumer report, if one is obtained by the Company, whenever you have a right to receive such a copy under state law.
Signature of applicant*
Date Signed (Today's Date)*
Date Format: MM slash DD slash YYYY
Full Name (First, MI, Last)*
Social Security Number**
*This information will be used for background screening purposes only and will not be used as hiring criteria.
Date of birth**
Date Format: MM slash DD slash YYYY

*This information will be used for background screening purposes only and will not be used as hiring criteria.
Driver's License Number and State*
Name: First, Middle Last
If you have used any other names in the past 7 years, please provide them here.
Name: First, Middle Last
If you have used any other names in the past 7 years, please provide them here.

MANDATORY USE FOR ALL ACCOUNT HOLDERS
IMPORTANT NOTICE REGARDING BACKGROUND REPORTS FROM: PSP ONLINE SERVICE

1. In connection with your application with Hi-Grade Materials ("Prospective Employer"), Prospective Employer, its employees, agents or contractors may obtain one or more reports regaring your driving and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).

When the application for employment is submitted in person, if the Prosptective Employer uses any information it obtains from the FMCSA in a decision to not hire you or make any other adverse employment decision by you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based on your driving history or safety report, the Prospective Employer will notify you the action has been taken and that the action was based in part or in whole on this report.

When the application for employment is submitted by mail, telephone, computer or any other means, if the Prospective Empllyer uses any informaion it obtains from FMCSA in a decision to not hire you or make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has bene taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll-free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of a driver record from the Prospective Employer who produced the report, then, within 3 business ndays of receving your request, together with proper identification, the Prospective Employer must send or provide you with a copy of your report and a summary of your rights under the Fair Credit Reporting Act.

The Prospective Employer cannot obtain background reports from FMCSA unless you consent in writing.

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

2. I authorize Hi-Grade Materials ("Prospective Employer") to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am consenting to the release of safety performance informaton including crash data from teh previous five (5) years and inspection history from the previous three (3) yeares. I understand and acknowlege that this release of informaiton may assist the Prospective Employer to make a determination regaring my suitability as an employee.

3. I further understand that neigher the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the cabability to correct my safety data that appears to be incorrect. I understand I may challenge the accurace of the data by submitting a request to http://dataqs.fmcsa.dot.gov. If I am challenging crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.

4. Please note: Any crash inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motoer Vehicle (CMV) crashes where you were a drive or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections with or without violations, appear on the PSP report. State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.

I have read the above Notice Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this consent form, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.
Date*
Date Format: MM slash DD slash YYYY
Signature of applicant*
Full Name (First, MI, Last)*
Applying to be a Class A or B Driver? Attach Your H-6 DMV printout
If applying to be a Class A or B Driver, If possible, please scan and upload a digital file of your H-6 DMV printout. NOTE: You can also email this DMV document to Jackie Stephens, Human Resources Manager, jstephens@robar.com, or fax it to: (760) 244-1819. You may also drop it off in person at any of our plant locations.

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PERSONAL INFORMATION

POSITION AND COMPANY APPLYING WITH

EMPLOYMENT HISTORY

EDUCATION

DRIVER'S LICENSE INFORMATION

OTHER INFO

EMERGENCY CONTACT INFO

PRE-EMPLOYMENT DRUG TESTING POLICY

APPLICANT'S STATEMENT

DISCLOSURE AND AUTHORIZATION

Notice Regarding Background Information

Additional State Law Notices

Authorization

MANDATORY USE FOR ALL ACCOUNT HOLDERS