DB+ Employee Information Sheet Employee Name First Last PhoneGender Male Female AgeDate of Birth MM slash DD slash YYYY Union Name Union Number Craft Wage Per hourJourneyman Or Apprentice (enter %) RaceWhiteBlackAsianAmerican IndianSpanishOtherFirst Day Worked for JRCC MM slash DD slash YYYY IN EVENT OF EMERGENCY PLEASE NOTIFY:Name First Last Relationship Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneAn essential function of this job may require climbing a minimum of six feet on a ladder or scaffold. Could you perform this task with or without reasonable accommodation? Yes No An essential function of this job may be doing repetitive overhead lifting for a minimum of eight hours a day. Could you perform this with or without reasonable accommodation? Yes No Another essential function of this job may be squatting, kneeing or crawling. Can you perform this with or without reasonable accommodation? Yes No This job may have an essential function of repetitious bending at the waist and lifting to a straight standing position, Can you perform this job with or without reasonable accommodation? Yes No An essential function of this job may require repetitious wrist and hand movement. Can you perform this job with or without reasonable accommodation? Yes No Another essential function of this job may require lifting a minimum of 25 pounds on a repetitive basis. Can you perform this function with or without reasonable accommodation? Yes No This job also may have an essential function of pushing and pulling materials that weigh a minimum of 20 pounds. Can you perform this job with or without reasonable accommodation? Yes No An essential function of this job may require the use of machinery that vibrates (Examples: drills, jackhammers, sanders, etc.). Can you perform this job with or without reasonable accommodation? Yes No This job also may have an essential function of driving company equipment (Examples: bulldozer, truck, cement mixer, etc.) for long periods of time. Can you perform this job with or without reasonable accommodation? Yes No Another essential function of this position may be repetitive twisting at the waist. Are you capable of this essential function with or without reasonable accommodation? Yes No An essential function of this job may be climbing stairs. Can you perform this job with or without reasonable accommodation? Yes No This job may have an essential function of gripping and working with fine materials Can you perform this job with or without reasonable accommodation? Yes No Please upload a photo of your drivers license.Max. file size: 1 MB.Please upload a photo of your Social Security Card.Max. file size: 1 MB.If Applicable, upload photos of front and back of your Alien Registration Card. Drop files here or Select files Max. file size: 2 MB, Max. files: 2. Comments or Note:
