(Dishonorable Discharge is not an absolute bar to employment and that other factors will be considered in making a final decision to hire or not hire.)

*Read and Sign*

I certify that I am the person named above and all questions have been answered truthfully. Any information found to the contrary will automatically disqualify my Application.

AFFIDAVIT FOR PHYSICAL PERFORMANCE

An apprentice Bricklayer, PCC, Stone or Plasterer is required to perform all phases of work in the construction industry. This will include working with hand tools & power tools, and being exposed to loud noise, hazardous machinery, hazardous voltages and respiratory irritants. It may also include prolonged standing, climbing, walking and repeated squatting, stretching and bending. Some work may be required under extreme temperatures ranging from 0 degrees (outside work in the winter) to extreme heat in summer. Additionally, everyday work may be at such temperatures and in confined areas where movement is greatly limited. An apprentice is expected to lift and move heavy supplies and equipment up to 100 pounds, and will also work from ladders, scaffolds and personnel lifts, which may exceed 100 feet. Ifyou have a clear understanding of the physical requirements of working in the construction industry as presented above, and you can make an honest statement affirming your ability to fully perform this work, then you should sign the following statement. You must also be willing to take and pass a drug if requested.

l, affirm that I can reasonably perform the work of an apprentice as outlined above."

A NON-DISCRIMINATORY APPRENTICESHIP PROGRAM