EMPLOYMENT APPLICATION Date: Date available to start work: If responding to a newspaper ad, please specify the name and/or location of the newspaper: Position desired: IPI Division / Area of Work: IPI Process Mechanical IPI Fire Protection IPI Fabrication Office/Administrative Other

PERSONAL DATA First Name: Middle Name: Last Name: Social Security #: Current Address (#, street, city, state, zip): Current Telephone: Permanent Address (#, street, city, state, zip): Permanent Telephone:

EDUCATION Name of School Location Years Credit Graduate? Degree Course/ Major Subject Yes No    Yes No    Yes No    Yes No

EMPLOYMENT HISTORY Present or last Employer: Address: Job Title: Start Date: End Date: Start Pay: End Pay: Reason for Leaving: Supervisor Name/Title: Supervisor Telephone: May we contact? Yes No Enter description of work and responsbilities Previous Employer: Address: Job Title: Start Date: End Date: Start Pay: End Pay: Reason for Leaving: Supervisor Name/Title: Supervisor Telephone: May we contact? Yes No Enter description of work and responsbilities Previous Employer: Address: Job Title: Start Date: End Date: Start Pay: End Pay: Reason for Leaving: Supervisor Name/Title: Supervisor Telephone: May we contact? Yes No Enter description of work and responsbilities

ADDITIONAL EXPERIENCE List any additional experience or special training

MILITARY Have you served or are you serving in the United States Armed services? Yes   No Dates of Service: Rank at Discharge: Nature of duties and any special training and honors received: Have you ever been dishonorably discharged from military service? Yes   No

RECORD Have you ever been convicted of or entered a plea of guilty to a felony? Yes   No If yes, explain fully: Have you ever entered a plea of no lo contendre to a felony? Yes   No If yes, explain fully:

RELATIVES Do you have any immediate family members employed within the industry? Yes   No If yes, name employer Name of relatives employed by Industrial Piping, Inc.: Occupation: Location:

PERSONAL REFERENCES Name (not a relative/employer): Address/Telephone Number: Occupation:

EMERGENCY CONTACT Contact Name/Relationship: Employer: Contact Address: Phone Number: Cell Phone Number: Beeper Number: Alternate Number:

ACKNOWLEDGEMENTS & SIGNATURE I have read and understand the Employment Application Terms and Conditions. IMPORTANT: Checking this box will serve as your digital signature. Applications will not be considered without your digital signature.

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