TECHNICIAN APPLICATION

Step 1 of 3

Name

First Middle Last Maiden

Present Address

Street Address City State ZIP Code

Time at Current Residence

Telephone

If under 18, please list age

Salary desired

How many hours can you work weekly?

Can you work nights?

Type of Employment Desired

FULL-TIME ONLY

PART-TIME ONLY

FULL OR PART TIME

Date available for work

How did you hear about Bully?

Days/Hours available to work

No Pref

Mon

Tues

Wed

Thurs

Fri

Sat

Sun

APPLICATION FORM WAIVER In exchange for the consideration of my job application by Bully Industrial (hereinafter called “The Company”) I agree that: Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either (in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of Bully Industrial or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the President/General Manager of the Company. Both the undersigned and Bully Industrial facts called for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contract. I also understand that (1) the Company has a drug and alcohol policy that provides for preemployment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations. I understand that, in connection with the routine processing of your employment application the Company may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics, and mode of living. Upon written request from me, the Company will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act.

Digital Signature

First Last

This Company is an equal opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications. Thank you for completing this application form and for your interest in our business.

Bully Industrial Employee Screening Release

APPLICANT/EMPLOYEE COMPLETE THE FOLLOWING 1. In connection with my application for employment, I understand that a consumer report or an investigative consumer report may be requested from HireRight, Inc., that will include information as to my character, general reputation, personal characteristics, mode of living and credit standing. a. I understand that as directed by company policy and consistent with the job described, that information such as but not limit to criminal and warrant records, social security number verification, credit and financial information, education, driving history, employment history, personal references, certifications and professional licenses, drug testing results, address history, and workers compensation records may be obtained. b. I understand that such information may be obtained by direct or indirect contact from former employers, schools, courts, public agencies, or any other agency or institution and through personal interviews with neighbors, friends, associates, acquaintances, or other persons who have such knowledge. 2. Medical and workers’ compensation information will only be requested in compliance with the Federal Americans with Disabilities Act (ADA) and/or any other applicable state laws. According to the Fair Credit Reporting Act, I am entitled to know if employment is denied because of information obtained by my prospective employer from a consumer reporting agency. If so, I will be notified and given the name and address of the agency or the source which provided the information. 3. I acknowledge that a telephonic facsimile (FAX) or photographic copy shall be as valid as the original. This release is valid for most federal, state and county agencies. 4. Additional State Law Notices:

California Applicants/Employees Only

I have the right to request a copy of my consumer report from HireRight, Inc. by checking this box. The report will be sent directly to me by HireRight, Inc. to my most current address listed. I understand that I have the right to inspect visually the files concerning me maintained by an investigative consumer reporting agency during normal business hours upon reasonable notice. The inspection can be done in person if I appear in person and furnish proper identification. I am entitled to a copy of the file for a fee not to exceed the actual cost of duplication. I am entitled to be accompanied by one person of my choosing, who shall furnish reasonable identification. The inspection can also be done via certified mail if I make a written request, with proper identification, for copies to be sent to a specified address. I can also request a summary of the information to be provided by telephone if I make a written request, with proper identification for telephone disclosure. I further understand that the investigative consumer reporting agency shall provide trained personnel to explain to me any of the information furnished to me. I will receive from the investigative consumer reporting agency a written explanation of any coded information contained in files maintained on me.

The nature and scope of the investigation is as follows:

I have a right to obtain a copy of this report. I understand that in the event that I am denied employment based in whole, or in part, on the information obtained in the HireRight, Inc. report, I will be provided a copy of the report and a description in writing of my applicable state rights.

The nature and scope of the investigation is as follows:

Maine Applicants/Employees Only: I have the right, upon request, to be informed of whether an investigative consumer report was requested. If requested my report will be obtained from HireRight, Inc, 5151 California, Irvine, CA 92617 1-866-521-6995. This is the nearest unit designated to handle inquires for HireRight, Inc on any reports issued concerning me. I have the right, under Maine law, to request and promptly receive from HireRight, Inc. copies of my consumer report(s).

Minnesota Applicants/Employees Only:

have the right to request a copy of my consumer report from HireRight, Inc. by checking this box. The report will be sent directly to me by HireRight, Inc. to my most current address listed. I also have the right upon my direct request to HireRight, Inc. to obtain a complete and accurate disclosure of the nature and scope of the consumer report. The disclosure obtained from HireRight, Inc. will be in writing and mailed or delivered within 5 days after the request for the disclosure was received or the consumer report was requested, whichever is later.

New Jersey Applicants/Employees Only: The specific nature and scope of the investigation involving personal interviews includes:

New York Applicants/Employees Only: I have the right, upon written request, to be informed of whether or not a consumer report was requested. If requested my report will be obtained from HireRight, Inc, 5151 California, Irvine, CA 92617 1-866-521-6995. I may inspect and receive a copy of my report by contacting HireRight, Inc.

Oklahoma Applicants/Employees Only:

I have the right to request a copy of my consumer report from HireRight, Inc. by checking this box. The report will be sent directly to me by HireRight, Inc. to my most current address listed.

Washington Applicants/Employees Only: I understand before I am denied employment based in whole, or in part, on the information obtained in the HireRight, Inc. report, I will be provided a copy of the report and a description in writing of my applicable state rights.

The following information is required by law enforcement agencies and other entities for positive identification purposes when checking public records. It is confidential and will not be used for any other purposes.

Enter Your Full Name as it Appears on Your License:

First Middle Last

Please List Other Names You Have Used:

Home Address:

Street Address City State ZIP Code

Phone#

Date of Birth

Drivers License Number:

State Issuing License:

By signing this form I hereby authorize, without reservation, any law enforcement agency, institution, information service bureau, school, employer, reference, insurance company, or any other source contact by HireRight, Inc. or its agent, to furnish the information described in Section 1. I hereby release the employer and agents and all persons, agencies, and entities providing information or reports about me from any and all liability arising out of the requests for or release of any of the above mentioned information or reports. I acknowledge that I have read and understood the Employee Screening Release Authorization form. I understand that if hired my consent will apply throughout the term of my employment.

Digital Signature

First Last

Phone

This field is for validation purposes and should be left unchanged.

337-224-6004

TECHNICIAN APPLICATION

Education

Employment History

Bully Industrial Employee Screening Release

The following information is required by law enforcement agencies and other entities for positive identification purposes when checking public records. It is confidential and will not be used for any other purposes.

Head Office

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