Last Name First Middle Initial s1

APPLICATION FOR EMPLOYMENT MID STATES ELECTRIC An Equal Opportunity Employer.

Last Name: First Name: Middle Initial: Social Security Number:

Street Address: City/State: Zip Code: Phone Number:

Email Address: Wage/Salary Desired: Full Time $_____/hour Part Time Position Desired: Date you can begin work? __/__/__ Are you 18 years of age or older? If hired, can you submit proof of legal eligibility to work in the United Yes No States? Yes No Referral Source News Paper (paper name)______Friend Company Web Site Employee (Name) ______Relative Job Service Other (please specify)______

Have you ever worked for Mid States Electric Inc. before? Yes No If you answered yes, indicate reason for leaving & dates employed______

Have you ever been convicted of or are you subject to pending charges that, if proven, could result in conviction of a felony? Yes No

If yes, please explain (a conviction will not automatically bar an applicant from employment consideration)

Do you have a valid Driver’s License? Yes No Driver Licens number______State Issued______Experation Date______Operator Commercial (CDL)

EMPLOYMENT HISTORY From (mm/yr) Company Telephone Number ( ) To (mm/yr) Address Final Salary $ /hr Supervisor Name/Title Your Position/Title May we contact this employer? Yes No If no, why? Responsibilities/Duties: Specific Reasons for Leaving:

Created 08/2013 From (mm/yr) Company Telephone Number ( ) To (mm/yr) Address Final Salary $ /hr Supervisor Name/Title Your Position/Title May we contact this employer? Yes No If no, why? Responsibilities/Duties: Specific Reasons for Leaving:

From (mm/yr) Company Telephone Number ( ) To (mm/yr) Address Final Salary $ /hr Supervisor Name/Title Your Position/Title May we contact this employer? Yes No If no, why? Responsibilities/Duties: Specific Reasons for Leaving:

OTHER EMPLOYMENT NOT LISTED ABOVE Telephone Name of Company Address Position held Dates Number (mm/yr-mm/yr)

Explain all gaps in employment to above history:

Created 08/2013 EDUCATION Number of Graduated Scholastic Name of School & Degree or years Standing Major Location Certificate attended Yes No (GPA) High School(s) College or University Business or Technical Other MILITARY SERVICE Have you served in Branch: Date Entered: Date Discharged: Rank at Discharge: the Armed Forces? Yes No Special Training Received in the Military

List below any special technical, professional or trade training you have had.

PROFESSIONAL REFERENCES Name Occupation/Relationship Years known Telephone Number

Created 08/2013 CAREFULLY READ EACH STATEMENT BEFORE SIGNING AT THE BOTTOM

I certify that all of the information provided in this employment application is true and complete to the best of my knowledge, and I authorize Mid States Electric Inc., to investigate all of the statements contained in this application, including a criminal background, credit history check, and drug/alcohol test, as applicable. I understand that any false or incomplete information may disqualify me from further consideration for employment and may result in my immediate discharge if discovered at a later date. Mid States Electric inc., has a policy on maintaining a drug-free workplace and I understand that this policy may require me during employment to randomly submit to a urinalysis to test for the presence of controlled substances and/or illegal drugs to be conducted by a contracted health facility, clinic or lab.

I authorize the investigation of any or all statements contained in this application and also authorize any person, school, current employer, past employers, and other organizations to provide information concerning my previous employment and other relevant information that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements.

This application is valid for only ninety days from the date signed above. If you want to be considered for job openings later than ninety days from the date signed, you must submit a new application.

If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either I or the employer can terminated the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law.

I also understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment.

I have read, understand, and agree to the above statements.

Signature: Date:

Created 08/2013 Self-identification for the Purposes of the EEO-1 Form

Mid States Electric is an Equal Opportunity Employer. As required by law, we must record certain information to be made a part of our Affirmative Action Program. Applicants for employment are also invited to participate in the Affirmative Action Program by reporting their status. In extending this invitation you are also advised that: (a) workers (applicants) are under no obligation to respond, but may do so in the future if they choose; (b) responses will remain confidential within the Human Resources Department; and (c) responses will be used only for the necessary information to include in our Affirmative Action Program. We are a company that values diversity. We actively encourage women and minorities to apply. Refusal to provide this information will have no bearing on your application and will not subject you to any adverse treatment.

Please complete the information requested below. Thank you for your cooperation.

Name: ______

Gender: Male Female

Please check all that apply (See reverse for definitions)

Hispanic or Latino White (not Hispanic or Latino) Black or African American (not Hispanic or Latino) Native Hawaiian or Pacific Islander (not Hispanic or Latino) Asian (not Hispanic or Latino) American Indian or Alaskan Native (not Hispanic or Latino) Two or More Races (not Hispanic or Latino) I do not wish to Self-Identify.

Created 08/2013 EEOC RACE/ETHNIC IDENTIFICATION CATEGORIES

White (Not Hispanic or Latino) A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Black or African American (Not Hispanic or Latino) A person having origins in any of the black racial groups of Africa.

Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

Asian (Not Hispanic or Latino) A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

American Indian or Alaska Native (Not Hispanic or Latino) A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.

Two or More Races (Not Hispanic or Latino) All persons who identify with more than one of the above five races.

Created 08/2013 Self-identification for Veteran Status (pre-offer)

This employer is a government contractor subject to the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires government contractors to take affirmative action to employ and advance in employment the following categories of veterans:

• Disabled veteran: o a veteran of the U.S. military, ground, naval, or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or o a person who was discharged or released from active duty because of a service connected disability.  Recently separated veteran: any veteran during the three-year period beginning on the date of such veteran’s discharge or release from active duty in the U.S. military, ground, naval, or air service  Active duty wartime or campaign badge veteran: a veteran who served on active duty in the U.S. military, ground, naval, or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.  Armed forces service medal veteran: a veteran who, while serving on active duty in the U.S. military, ground, naval, or air service, participated in a U.S. military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

Please print your name below and indicate whether you belong to any of the above-mentioned categories of protected veterans.

Note: As a government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA. Submission of this information is voluntary. Refusal to provide it does not subject you to any adverse treatment. The information provided will be kept confidential and used only in ways that are consistent with the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended.

Name: ______

I identify as one or more of the classifications of protected veteran listed above (there is no need to identify the specific category at this time). I am not a protected veteran. I choose not to provide any information regarding my veteran status (you may choose to provide this information at any time in the future).

Created 08/2013 [OVER]

About our affirmative action plan

The Company’s affirmative action plan asserts and outlines our commitment to ensuring that our policy of nondiscrimination and affirmative action is accomplished. Specifically, the company does not discriminate on the basis of veteran status and works to employ and advance in employment qualified protected veterans.

The company’s affirmative action efforts include a regular review of personnel processes and the physical and mental job qualification standards for individual positions. They also include employee training, efforts to prevent harassment, and data collection and reporting systems to ensure nondiscrimination.

Created 08/2013