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Our company periodically produces statistical reports on the composition of the Company's applicants for employment. These questions assure full compliance with the Company's policy on Affirmative Action and non-discrimination. Completion of these questions is voluntary and the answers shall not be used for making decisions on any individual applicant.

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JOB TITLE: Administrative Supervisor
LOCATION: Parkersburg, WV (Ready-Mix)

Which of the following statements is accurate? I am authorized to work in the US I can work in the US for my present employer only I require sponsorship to work in the US I am authorized to work in Canada
Will you now or in the future require sponsorship for an employment visa?
If Yes, Please describe.

Name:
Address:
City:
State:
Zip:

Email:
Phone:
Gender:	Male Female
Are you a recruiter? Yes No-I'm the applicant

Ethnic Group Status (Check One):
White (Not Hispanic/Latino) Hispanic/Latino American Indian or Alaskan Native Black (Not Hispanic/Latino) Asian Native Hawaiian or Other Pacific Islander 2 or more races (Not Hispanic/Latino)
Have you ever served in the U.S. Armed forces for a period of time in which a ribbon or campaign badge has been awarded? (US applicants only)
Yes No
Did you ever serve on active duty with the U.S. Armed forces for at least 180 days during the Vietnam Era (8/5/64 - 5/7/75)? (US applicants only)
Yes No

How have you heard about this opening? (check all that apply)

	Internet Job Board
	State Unemployment Service
	Employee Referral
	Professional Journal
	Newspaper ad
	Recruiter
	Surfed www.essroc.com
	Community Agency

Cement/Ready-Mix Industry Experience:
Prior work experience:
Industrial Mfg Experience:
Current Company
Company Name:
Industry:
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Reason for leaving:
Previous Company
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Salary Requirements:
Relocation:
If you selected "yes" for relocation, please supply your preference.
Unofficial Transcript:
Attach Unofficial Transcript:
NOTE: Unofficial transcripts must accompany all applications for the JET Development Program applications.

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