Application For Employment

Wingra Redi-Mix, Inc. & Wingra Stone Company P.O. Box 44284 Madison, WI 53744-4284

No person who operates a commerical motor vehicle shall at any time have more than one driver's license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below. Include all licenses held for the past 3 years.

Only list the highest level of schooling completed

In accordance with EEOC Americans with Disabilities Act Regulations, 1630.2 (g) and Section 504 of the Rehabilitation Act of 1973, a "Disabled Person" is defined as any person who:

• 1. Has a physical or mental impairment which substantially limits one or more major life activities.

• 2. Has a record of such and impairment.

• 3. Is regarded as having such an impairment.

I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, medical history, and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, health care providers, and other persons from all liability in responding to inquiries and releasing information in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I also understand that I am required to abide by all rules and regulations of the Company. I understand that the information I provide regarding my current and/or prior employers may be used, and those employer(s) will be contacted for the purpose of investigating my safety performance history as required by 49 CFR 391.23. I understand that I have the right to: • Review information provided by current/previous employers; • Have errors in the information corrected by previous employers, and for those previous employers to resend the corrected information to the prospective employer; and • Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.