JAKES, INC. APPLICATION FOR EMPLOYMENT

1 JAKES, INC. APPLICATION FOR EMPLOYMENT SELECTION CRITERIA: To be hire d by this compan y yo u must be qualified and ab le to do al l ess ent ial func tions of the job; re fere nc es must be favorable; job history (as stated on this ap plicat ion) must be verifiabl e; former employers must conf irm yo ur ex perienc e, ski lls and de pendab ility; yo u must be tru thful on the ap pli ca ti on an d in the int erv iews conducted by and for this company and al l su ch informati on must be veri fiabl e; dri ving and cre dit history must be ac cep table.

2 You must pass re quired medical and drug test ing ; any clai ms for mone tary damag es you hav e mad e while re pre sented by an at torney must be deemed re aso nable and justi fiab le; you must be tru thful in any post job off er inq uiri es about your he alt h, worker s compensati on hist ory and med ica l su it abi lity for this job; and you must be ab le to meet all se lection stan dards mandat ed bylaw. APPLICANTS ARE CONSIDERED FOR ALL POSITIONS WITHOUT REGARD TO RACE, RELIGION, SEX, NATI ONAL ORIGIN, AGE, MARITAL OR VETERAN STATUS, THE PRESENCE OF A NON-JOB-RELATED MEDICAL CONDI TION OR DISABIL ITY, OR ANY OTHER LEGALLY PROTECTED STATUS.

3 NO APPLICATION WILL BE CONSIDERED UNLESS ALL INFORMATION REQUESTED ON THIS FORM IS COMPLETED IN I NFORMATION PRINT IN BLOCK, CAPITAL LETTERSFI RST NAMEMIDDLE NAMELAST NAMEADDRESSCITY/S TATE/ZIPPHONE NUMBERPosi tion Applied for: Sourc e of Referr al : _____ Emerg ency Telephone #/Cont ac t Perso n:Have yo u ever bee n employed by or ap plied for work at this company?YesNoDo any of yo ur family membe rs curr ent ly work at this company?YesNoIf yes, listHighe st level of educat ion completed?Where an d When?Have yo u ever bee n conv icted of any cri mina l off ense (misd emeanor or felony )?

4 YesNoList year, charg e an d outcome of eac h off ense:Have yo u ever plead gu ilty or no lo cont endere (no cont est) to a crimina l charg e in ord er to quali fy for de ferr ed ad judicat ion?YesNoIf yes, list .Have yo u ever bee n on any type of pro bation as a re su lt of a cri minal charge? YesNoIf yes, list .If yo u are curre ntl y charged with a criminal off ense and awaiting trial please ex plain:Has your driver s li cense ever be en su sp ended?YesNoIf yes, list .Have yo u ever bee n charged wi th DWI or DUI?YesNoIf yes, list .List ti cke ts (moving violat ions) received in the past 3 al l vehicular ac cide nts in the las t 3 yo u ever use d an at torney to han dle a claim, see k mone tary damag es or file a lawsuit?

5 YesNoIf yes, lis t all su ch occ asions and dic at e the Languag es you sp eak, read , and/o r writ e: _____ Page 2Pl ease list LAST 4 JOBS, beginn ing wi th yo ur present or last employer. Acco unt for ALL ti me peri ods, inc luding UNEMPLOYMENT, SELF- EMPLOYMENT , an d MILITARY SERVICE. If sp ac e is insuff icient to go back seven (7) years, use an addit ional sh eet of pape r. Inc lude par t-ti me and temporary we call yo ur prese nt emplo yer? Yes _____ No yerDates FromPosit io n Held :Equip ment Use d:AddressFromMont h _____Year_____Phone# ()-CitySt at eToMont h _____Year_____Supervisor:Reas on For Leav in yerDates FromPosit io n Held : Equip ment Use d::AddressFromMont h _____Year_____Phone# ()-CitySt at eToMont h _____Year_____Supervisor:Reas on For Leav in yerDates FromPosit io n Held :Equip ment Use d: AddressFromMont h _____Year_____Phone# ()-CitySt at eToMont h _____Year_____Supervisor:Reas on For Leav in yerDates FromPosit io n Held : Equip ment Use d.

6 AddressFromMont h _____Year_____Phone# ()-CitySt at eToMont h _____Year_____Supervisor:Reas on For Leav in g:Are yo u a vetera n of the U. S. Mili tary Se rvic e? Yes ____ No ____ List Bra nch and Dat es _____Page 3 APPLICANT AGREEMENT: In order fo r the se le ctio n criteria of JAKES, INC to be satisf ie d, I authorize and re quest inquiries by The Cole Group to verifymy jo b his tory, medic al hist ory, worke rs compensa tio n cla ims, educat io n, credit hist ory, invo lve ment in prio r lit ig atio n and criminal court rec ords. I hereby release from li ability and hold harmless: The Cole Group, JAKES, INC, and any co ntrib ut ing fir m, indiv idual, organizat io n, or rec ords deposit ory an d all of their off ic ers, employees and ag ents.

7 I specifically authorize the release of all recordsfr om The Cole Group, fo rmer emplo yers (inclu ding pay roll/att endance info rmatio n), insu ra nce companies, United St at es Distric t Courts, County an d St at e District Court , Indust rial Accid ent Boar ds, hospit als (a nd/o r) att ending physi cia ns and therapist s, Department of Public Safety (State Police), Fe deral Agencie s an d Credit Reporting Fi rms. I hereby give my vo luntary consen tfo r necessary drug sc ree ni ng test s and the resu lts to be report ed to jake s, Inc. If emplo yment has bee n off ered, I underst and that it is temporary and conditio nal until al l info rmat io n is verif ie d, and that misstat ements or omissions of fac t sh all be cau se fo r immediate dismissal or wit hdrawal of the conditio nal off er.

8 Notic e: If The Cole Group proce sses th is ap plicatio n and you ar e not offered emplo yment, yo u may write to The Cole Group at 5225 Katy Fr ee way, Suit e 250, Houst on, Texas 77007 and request the nature of an y ad verse in fo rmat io n in the report. I understand th at my EMPLOYMENT is fo r no ce rtai n perio d of time and that I ca n be terminated from, or quit this job , wit hout notic e bein g given by either party. I agree to comply with all rule s of this company if hire d, including its policie s of drug and alc ohol test ing. I CERTIFY THAT THE INFORMATION GIVEN BY ME IN THIS APPLICATION IS TRUE IN ALL RESPECTS.

9 Signature Date To est ab lish that I meet the ab ove refe rence d qual if ic at io n re quir ement s fo r emplo yment wit h JAKES, INC I vo lu ntaril y prov id ethe belo w in fo rmat io n: (PRINT IN CAPITAL BLOCK LETTERS) List any other last names yo u hav e eve r use d (maid en/f ormer marr ie d) and the sp ecif ic year s use of Bir th:Social Se curit y NumberDriver s Lic ense NumberSt at eType of Lic ense : Class C _____ CDL-Cl ass A _____ CDL-Class B _____ Expiratio n Dat e: _____Are yo u a cit iz en or do you possess a valid Work Pe rmit permit ting emplo yment? Yes _____ No _____Can you prov id e documented proof of yo ur eligib il it y fo r emplo yment in the United Stat es?

10 Yes _____ No _____Have yo u eve r livedanywhere other than Texas? If so , ple ase list belo e of residence and the sp ecif ic year s lived there si nce the ag e 18:CitySt at eFr omToPr ese ntADDITIONAL APPLICANT AGREEMENT: Any person hire d by Ja ke s, Inc. that does not remain employed through the probationary period of ninety (90) day s will be held re sponsib le for reimbursement to Ja ke s for the outside screening cost of $ . This amount will be deducted from yo ur final check. Agreed To: _____ Date: _____In terviewer: _____ Date: _____In terviewer: _____ Date: _____In terviewer: _____ Date: _____Employed : Yes _____ No _____Date of Employmen t: _____Hourl y / Salar y Rat e: _____Jo b Ti tle: _____ Depar tment: _____Signed : _____ Date: _____Ti tle: _____