Application for Employment Personal and Confidential

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Application for Employment
Personal and Confidential
IMPORTANT

CEMEX provides equal employment opportunity for all persons without
regard to race, color, creed, sex, religion, marital status, age, national
origin or ancestry, physical or ment
al disability, medica l condition,
sexual orientation, or any other consideratio n protec ted by federal,
state or local laws.

CEMEX maintains a drug free workplac
e. When required by the
position, y ou will be required to ta ke a physical exam ination and/or a
drug and alcohol screen as a condition of employment or continued
employment.

You will be required to furnish info rmation that would allow CEM EX to
verify your records including, but not limited to, past employment,
education, driving record, credit, so cial s ecurity number, and felony
and serious misdemeanor convictions as a condition of employment or
continued employment.

You will be required to furnish s atisfactory proof of citizenship or legal
alien status in compliance with the Immigration Reform and Control Act
as a condition of employment or continued employment.

References to “CEMEX” include CE MEX, Inc. and al l CEMEX, Inc.
subsidiaries and affiliates in the United States.
Revised 10/2009
PERSONAL INFORMATION
(Print) First Name
Middle Name
List Residence for Past 3 Years
Current Address
City
Previous Address
City
Previous Address
City
Last Name
Social Security Number:
State
-
-
Zip
Yrs. at
Address
State
Zip
Yrs. at
Address
State
Zip
Yrs. at
Address
Telephone:  Home  Work
Telephone:  Home  Work
Email:  Home  Work
Are you at least 18 years old?
Are you legally eligible for
employment in the U.S.?
If hired, would you have a reliable means of
transportation to and from work?
 YES
 YES  NO
 NO Eligibility requires a valid work permit  YES  NO
Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable
accommodation?
 YES  NO Describe the functions that cannot be performed: _____________________________________________
___________________________________________________________________________________
Have you ever been convicted of a crime (felony or misdemeanor)? (Conviction does not guarantee employment disqualification)
 NO  YES Describe nature of crime(s) and when convicted: ______________________________________________
____________________________________________________________________________________
Position applying for:
POSITION INFORMATION
Desired Status:
Desired Shift:
Desired Pay:
Available to work:
 Full-Time  Temporary
 First  Second  Hour: _______ Weekends?  Yes  No
 Part-Time  Seasonal
 Third  Any
 Month: ______ Overtime?  Yes  No
Date available for work:
Days available for work:
List any upcoming dates you are not available to work:
Have you ever applied or worked with CEMEX before?
Applied:  No  Yes Mo. _________ Year ________
Worked:  No  Yes Mo. _________ Year ________
Branch of U.S. Service
 Navy  Air Force  Coast
 Army  Marines
Guard
Have you ever held a supervisory position?
 No  Yes Company: ________________________________
Title: __________________ No. of employees supervised: _____
MILITARY STATUS
Dates of Active Duty
Describe any military training received relevant to the position for
which you are applying.
REFERENCES
List three (3) non-relatives whom you have known for at least one year.
Reference Type: Print Full Name:
Address
 Personal
 Professional
Reference Type: Print Full Name:
Address
 Personal
 Professional
Reference Type: Print Full Name:
Address
 Personal
 Professional
Phone
Profession
Yrs.
Known
Phone
Profession
Yrs.
Known
Phone
Profession
Yrs.
Known
EDUCATION
School
Name and Address
Course of Study
Yrs.
Completed
Date
Graduated
Diploma or
Degree
High School
 Trade School
 College/University
 Trade School
 College/University
WORK EXPERIENCE
List all employment for the last ten (10) years beginning with your present, or most recent, job held. Account for all periods
of unemployment. You may attach a separate page if needed. You must complete this section even if attaching a resume.
Employer
Street Address
City, State
Zip Code Telephone
Dates
From
To
Duties Performed:
May we contact
this employer?
 YES  NO
Employer
Dates
From
To
Duties Performed:
May we contact
this employer?
 YES  NO
Employer
Dates
From
To
Duties Performed:
May we contact
this employer?
 YES  NO
Employer
Dates
From
To
Duties Performed:
May we contact
this employer?
 YES  NO
Position Held:
Last Supervisor:
Salary:
Reason for Leaving:
Were you subject to the Federal Motor Carrier
Safety Regulations while employed with this
employer?
 YES  NO
Street Address
Position Held:
Was your job designated as a safety sensitive function
by DOT and subject to alcohol and controlled substance
testing as required by 49 CFR 40?
 YES  NO
City, State
Zip Code
Last Supervisor:
Telephone
Salary:
Reason for Leaving:
Were you subject to the Federal Motor Carrier
Safety Regulations while employed with this
employer?
 YES  NO
Street Address
Position Held:
Was your job designated as a safety sensitive function
by DOT and subject to alcohol and controlled substance
testing as required by 49 CFR 40?
 YES  NO
City, State
Zip Code
Last Supervisor:
Telephone
Salary:
Reason for Leaving:
Were you subject to the Federal Motor Carrier
Safety Regulations while employed with this
employer?
 YES  NO
Street Address
Position Held:
Was your job designated as a safety sensitive function
by DOT and subject to alcohol and controlled substance
testing as required by 49 CFR 40?
 YES  NO
City, State
Last Supervisor:
Zip Code
Telephone
Salary:
Reason for Leaving:
Were you subject to the Federal Motor Carrier
Safety Regulations while employed with this
employer?
 YES  NO
Was your job designated as a safety sensitive function
by DOT and subject to alcohol and controlled substance
testing as required by 49 CFR 40?
 YES  NO
DRIVING EXPERIENCE
Complete this section only if you are applying for a commercial driving position.
Drivers License No.
Issuing State
Year of Expiration
Is your license valid?
 YES  NO
Have you had any moving violations in the past ten (10) years?
 YES  NO
List dates and violation: ________________________________________________________________________________
Type of Equipment
Straight Truck
Years of Experience
Number of Miles
Certifications/Licenses
Tractor/Semi-Trailer
Tractor/Full-Trailer
Twin Trailers
List all states licensed in over the past ten (10) years. Include Drivers License number and issuing state for each one listed.
Have you ever tested positive, or refused to test, on any pre-employment drug or alcohol screen administered by an
employer for which you applied but did not obtain safety-sensitive transportation work covered by DOT drug and alcohol
testing in the past two (2) years?
 YES
 NO
QUALIFICATIONS/CERTIFICATIONS
List all current licenses and/or certifications you have received. List all equipment you can operate proficiently. List any
training, skills, qualifications or other information relevant to the type of employment you are seeking.
ACKNOWLEDGEMENT AND RELEASE
Please read carefully and initial each paragraph and sign below.
Initial I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that
Initial
Initial
the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have
personally completed this application. I understand that any omission or misstatement of material fact of this application or any
document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am
employed, regardless of the time elapsed before discovery.
I hereby authorize CEMEX to thoroughly investigate my references, work record, education, and other matters related to my
suitability for employment and further authorize the references I have listed to disclose to the company any and all letters, reports
and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release
the company, my former employers and all other persons, corporations, partnerships and associations from any and all claims,
demands or liabilities arising out of or in any way related to such investigation or disclosure.
I understand that employment at CEMEX is “at will,” which means that either I or the company can terminate the employment
relationship at any time, with or without prior notice, and for any reason not prohibited by statute. I also understand that all
employment is continued on the “at will” basis, and that if I am employed, only an officer, or the President of CEMEX, has the
authority to alter the “at will” employment relationship.
Signature of Applicant:
Date:
For Office use only!
Received in Human Resources
OFFICE USE
Applicants: Do not write in this section.
Forwarded to:
Date ________________ Time _____________
Interview:
Start Date
Rate
 YES, Date ______________ Time_________
 NO
Verification Checks Required
 DMV
 SSN
 Criminal
 Education
 Employers
 Credit
Date
Position
 Drug/Alcohol
 Physical
BACKGROUND CHECKS REQUEST FORM
FAX TO: (918) 401-2129
Payroll Transactions & Support Services (PRTSS)
Document NEEDED for background check:
 This cover sheet - ONE (1) cover sheet for EACH final applicant
 Applicant’s signed Sterling consent and disclosure form
 Copy of the employment application
Please complete ALL fields in the below sections as requested.
Date:
Requestor:
Contact #:
Non-Commercial/Fleet
Company Vehicle Eligible? Plant #:
Yes
No
Position Applied For:
Estimated Base Salary:
Name of Hiring Manager:
Please clearly print Applicant’s name, SS#, driver’s license, DOB, and current address.
Applicant’s name must be provided as it appears on the social security card.
Last Name
First Name
Middle Name
Other names known by:
-
SSN:
-
Date of Birth:
State:
Driver’s License #:
Expiration:
**EMPLOYMENT VERIFICATION – Contact Current Employer? **
Yes
No
*** COMPLETE ADDRESS INFORMATION NEEDED TO COMPLETE BACKGROUND CHECK ***
STREET
CITY
STATE
ZIP
HOW LONG
ADDITIONAL COMMENTS/REQUESTS:
Shared Services PRTSS USE ONLY:
Basic DOT
Basic Non-DOT
Management
Full Background Check
Intermediate
Executive
Additional Check
Order Entry Date: __________________
Employment Verification
Order Number:
MVR Check Only
__________________
Remedy Case No.: __________________
Order Entry Date: __________________
SSN Results:
Order Number:
Results:
Valid
Clear
Invalid
__________________
Adverse
Results sent to Requestor:
Processor’s Notes:
Date: ___________ By: _____________
CEMEX USA Shared Services
HR062 Background Check Request
Rev. 10/2009
Page 1 of 1
Consent to Request Consumer Report & Investigative Consumer Report Information
Applicant's First Name or Initial
Last Name
I understand that CEMEX (‘COMPANY’) will utilize the services of Sterling InfoSystems Inc., 249 West 17th Street, New York, NY 10011,
(877) 424-2457 to obtain a consumer report and/or investigative consumer report as part of the procedure for processing my application for
employment. I also understand that if my application for employment is granted, to the extent permitted by law, COMPANY may obtain further
information through subsequent investigations by STERLING so as to update, renew or extend my employment.
I understand Sterling InfoSystems Inc. (“STERLING”) investigation may include obtaining information regarding my credit background,
bankruptcies, driving record, lawsuits, judgments, paid tax liens, unlawful detainer actions, failure to pay spousal or child support, accounts placed
for collection, and criminal record, subject to any limitations imposed by applicable federal and state law. I understand such information may be
obtained through direct or indirect contact with former employers, schools, financial institutions, landlords and public agencies or other persons who
may have such knowledge. If an investigative consumer report is being requested, I understand such information may be obtained through any
means, including but not limited to personal interviews with my acquaintances and/or associates or with others whom I am acquainted or who may
have knowledge concerning my character, general reputation, personal characteristics or standard of living.
The nature and scope of the investigation sought is as follows: Social Security Address Trace, Criminal Record Search, Employment
Reference
I acknowledge that I have received the attached summary of my rights under the Fair Credit Reporting Act and, as required by law, any related
state summary of rights.
This consent will not affect my ability to question or dispute the accuracy of any information contained in my report. I understand if COMPANY
makes a conditional decision to disqualify me based all or in part on my report, I will be provided with a copy of the report and another description
in writing of my rights under the federal Fair Credit Reporting Act and, as required by law, any related state summary of rights, and if I disagree
with the accuracy of the purported disqualifying information in the report, I must notify COMPANY within five business days of my receipt of the
report that I am challenging the accuracy of such information with Sterling InfoSystems Inc.
I hereby consent to this investigation and authorize COMPANY to procure a consumer report(s) and/or investigative consumer report on my
background as stated above from a consumer reporting agency and/or investigative consumer reporting agency.
In order to verify my identity for the purposes of background identification, I am voluntarily releasing my date of birth, social security number and
the other information below for my own benefit and fully understand that all employment decisions are based on legitimate non-discriminatory
reasons.



California, Minnesota & Oklahoma Applicants Only: I have the right to request a copy of the consumer report obtained by
COMPANY from STERLING by checking the box. STERLING will mail the consumer report directly to me. I wish to receive a copy of the
consumer/investigative consumer report. (Check only if you wish to receive a copy.)
Maine Applicants Only: By checking the box, I indicate that I wish to receive the name, address and telephone number of the nearest unit
of the consumer reporting agency designated to handle inquiries regarding the investigative consumer report.
Washington State Applicants Only (AS APPLICABLE): I further understand that COMPANY will not obtain information about my
“credit worthiness, credit standing, or credit capacity” unless the information is required by law, or is substantially job related, and the
reasons for using the information are disclosed to me in writing. (If this option is checked, complete the question below.) Reasons why
COMPANY considers information about “credit worthiness, credit standing, or credit capacity” as substantially job related:
________________________________________________________________________________________
NY Applicants Only: I also acknowledge that I have received the attached copy of Article 23A of New York’s Correction Law. I further understand
that I may review and receive a copy of any investigative consumer report by contacting the consumer reporting agency. I further understand that I
will be advised if any further checks are requested and provided the name and address of the consumer reporting agency.
California Applicants and Residents: If I am applying for employment in California or reside in California, I understand I have the right to
inspect visually the files concerning me maintained by an investigative consumer-reporting agency during normal business hours and 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 costs 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 addressee.
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, and the toll charge, if any, for the telephone call is prepaid by or directly charged to me. 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 shall receive from the investigative consumer reporting agency a written explanation of any coded information contained in files maintained
on me. “Proper identification” as used in this paragraph means information generally deemed sufficient to identify a person, including documents
such as a valid driver’s license, social security account number, military identification card and credit cards.
_______________________________________________________________________________
______________________
Signature:
Today’s Date:
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12/2008
C
E
M E
X
For Office Use Only – Group ID (optional)
For Office Use Only – User ID (optional)
For Office Use Only – Location / Store # (optional)
First Name
Middle Name or Initial
Last Name
Date of Birth (MMDDYYYY)
Other Names Known By
Social Security Number
Male
Primary Telephone Number (no dashes)
Current Address
City
Female
Apt #
State
Previous Address
Zip Code
Apt #
City
State
Driver’s License Number (no dashes)
License State
#yrs at this address
#yrs at this address
Zip Code
Email Address
Signature
Today’s Date (MMDDYYYY)
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249 West 17th Street, 6 Floor, New York, NY 10011  Telephone 212-812-1020  877-424-2457  Facsimile 646-536-5239
12/2008
Para informacion en espanol, visite http://www.ftc.gov/credit o escribe a la FTC Consumer Response Center,
Room 130-A 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.
A Summary of Your Rights Under the Fair Credit Reporting Act
The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of
consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and
specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental
history records). Here is a summary of your major rights under the FCRA. For more information, including information
about additional rights, go to http://www.ftc.gov/credit or write to: Consumer Response Center, Room 130-A, Federal
Trade Commission, 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.

You must be told if information in your file has been used against you. Anyone who uses a credit report or
another type of consumer report to deny your application for credit, insurance, or employment – or to take another
adverse action against you – must tell you, and must give you the name, address, and phone number of the
agency that provided the information.

You have the right to know what is in your file. You may request and obtain all the information about you in the
files of a consumer reporting agency (your “file disclosure”). You will be required to provide proper identification,
which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a
free file disclosure if:
o
a person has taken adverse action against you because of information in your credit report;
o
you are the victim of identify theft and place a fraud alert in your file;
o
your file contains inaccurate information as a result of fraud;
o
you are on public assistance;
o
you are unemployed but expect to apply for employment within 60 days.
In addition, by September 2005 all consumers will be entitled to one free disclosure every 12 months upon request
from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See
http://www.ftc.gov/credit for additional information.

You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness
based on information from credit bureaus. You may request a credit score from consumer reporting agencies that
create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some
mortgage transactions, you will receive credit score information for free from the mortgage lender.

You have the right to dispute incomplete or inaccurate information. If you identify information in your file that
is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless
your dispute is frivolous. See http://www.ftc.gov/creditfor an explanation of dispute procedures.

Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information.
Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days. However,
a consumer reporting agency may continue to report information it has verified as accurate.

Consumer reporting agencies may not report outdated negative information. In most cases, a consumer
reporting agency may not report negative information that is more than seven years old, or bankruptcies that are
more than 10 years old.

Access to your file is limited. A consumer reporting agency may provide information about you only to people
with a valid need -- usually to consider an application with a creditor, insurer, employer, landlord, or other
business. The FCRA specifies those with a valid need for access.

You must give your consent for reports to be provided to employers. A consumer-reporting agency may not
give out information about you to your employer, or a potential employer, without your written consent given to the
employer. Written consent generally is not required in the trucking industry. For more information, go to
www.ftc.gov/credit.
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249 West 17th Street, 6 Floor, New York, NY 10011  Telephone 212-812-1020  877-424-2457  Facsimile 646-536-5239
12/2008
You may limit “prescreened” offers of credit and insurance you get based on information in your credit report.
Unsolicited “prescreened” offers for credit and insurance must include a toll-free phone number you can call if you
choose to remove your name and address from the lists these offers are based on. You may opt-out with the
nationwide credit bureaus at 1-888-5-OPTOUT (1-888-567-8688).

You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer
reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in
state or federal court.

Identity theft victims and active duty military personnel have additional rights. For more information, visit
www.ftc.gov/credit.
States may enforce the FCRA, and many states have their own consumer reporting laws. In some
cases, you may have more rights under state law. For more information, contact your state or local
consumer protection agency or your state Attorney General. Federal enforcers are:
FOR QUESTIONS OR CONCERNS REGARDING
PLEASE CONTACT
Federal Trade Commission
Consumer reporting agencies, creditors and others not
Consumer Response Center- FCRA
listed below
Washington, DC 20580 - 877-382-4357
National banks, federal branches/agencies of foreign
banks (word "National" or initials "N.A." appear in or
after bank's name)
Office of the Comptroller of the Currency
Compliance Management, Mail Stop 6-6
Washington, DC 20219 - 800-613-6743
Federal Reserve System member banks (except
national banks, and federal branches/agencies of
foreign banks)
Federal Reserve Board
Division of Consumer & Community Affairs
Washington, DC 20551 - 202-452-3693
Savings associations and federally chartered savings
banks (word "Federal" or initials "F.S.B." appear in
federal institution's name)
Office of Thrift Supervision
Consumer Programs
Washington D.C. 20552 - 800- 842-6929
Federal credit unions (words "Federal Credit Union"
appear in institution's name)
National Credit Union Administration
1775 Duke Street
Alexandria, VA 22314 - 703-519-4600
State-chartered banks that are not members of the
Federal Reserve System
Federal Deposit Insurance Corporation
Division of Compliance & Consumer Affairs
Washington, DC 20429 - 877-275-3342
Air, surface, or rail common carriers regulated by former Department of Transportation
Civil Aeronautics Board or Interstate Commerce
Office of Financial Management
Commission
Washington, DC 20590 - 202-366-1306
Activities subject to the Packers and Stockyards Act,
1921
Department of Agriculture
Office of Deputy Administrator-GIPSA
Washington, DC 20250 - 202-720-7051
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249 West 17th Street, 6 Floor, New York, NY 10011  Telephone 212-812-1020  877-424-2457  Facsimile 646-536-5239
12/2008
CONSENT AND RELEASE FORM
FOR PRE-EMPLOYMENT, RANDOM, OR REASONABLE SUSPICION DRUG
AND/OR ALCOHOL TESTING
I hereby consent, upon a request made under the drug/alcohol testing policy of CEMEX and its
subsidiaries and affiliates (referred to as “CEMEX” or the “Company”), to submit to a drug or alcohol test
and to furnish a sample of my urine, breath and/or blood (if applicable) at a designated collection site for
analysis. I further consent to give full permission and allow a certified laboratory testing service to
release of the results of said tests to an authorized medical review officer (MRO), the Company, or
authorized agents of the Company.
I further agree to hold harmless the Company and its agents (including the collection site and any testing
laboratory the Company might use), from any liability arising in whole or part out of the collection of
specimens, testing, and use of the information from said testing in connection with the company’s
consideration of my employment or any other kind of adverse job action.
I further agree a reproduced copy of this consent and release form shall have the same force and effect
as the original.
I also hereby certify that I have received and read the Drug and Alcohol Abuse Policy and have had the
drug-free workplace program explained to me, and I have been told that if I have any questions about the
test or the policy, they will be answered. I understand and agree that if I at any time refuse to submit to a
drug or alcohol test under the company policy, or if I otherwise fail to cooperate with the testing
procedures, or a confirmed positive result for the illegal use of drugs and/or alcohol will be subject to
immediate termination or employment withdrawal.
I have carefully read the foregoing any fully understand its content.
Applicant/Employee:
__________________________________
Signature
__________________
Date
__________________________________
Print Name
Witness:
__________________________________
Signature
__________________
Date
__________________________________
Print Name
HR063 Drug & Alcohol Consent and Release Form
V. 12/2007
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