F.S. Lopke Contracting, Inc. 3430 State Rte. 434, Apalachin, NY 13732

EMPLOYMENT APPLICATION F.S. Lopke Contracting, Inc. 3430 State Rte. 434, Apalachin, NY 13732 Phone: 607-687-1114 Fax: 607-687-1856

Name: ______Phone: ______

Address: ______

City: ______State: ______Zip: ______

Social Security #: ______Drivers License #: ______

Position Desired: ______

Rate of Pay: ______High School: ______Trade School: ______Employment History College: ______Last Job First Special Skills: ______

Employer: ______Begin: ______End: ______Address: ______Person directly worked for: ______Phone: ______Position held/duties: ______Rate of Pay: ______

Personal References: Name:______Address: ______Phone: ______Name:______Address: ______Phone: ______Name:______Address: ______Phone: ______

When Could You Start Work: ______

Application Date: ______Signature: ______

Application must be filled out completely to be deemed complete. All potential employees must pass a pre-employment drug test before beginning work.

“A Drug Free Workplace”