1163 Millwright Application

6489 Riding Road, Syracuse, NY 13206 PH: 315-671-0672 Email: local1163@nasrcc.org

Application Date

Date

Last Name*

First Name*

Middle Name

My Preferred Name Is

Gender

MALEFEMALEDO NOT WISH TO ANSWER

Email Address*

example@example.com

Phone Number*

Address*

Mailing Address

Street Address Line 2

CityState

Zip

Vaild Driver License?

YESNO

Driver License #

State of Driver License

Do you have reliable transportation to and from various jobsites and required classes at the approved school?*

YESNO

Do you reside within the jurisdiction of Eastern Millwright Regional Council, which includes all counties in New York State with the exception of Dutchess, Nassau, Orange, Putnam, Rockland, Suffolk, Westchester, Kings, Queens, Bronx, New York and Richmond?*

YESNO

Legally eligible to work in the U.S.*

YESNO

Are you a Veteran?*

YESNO

Branch of Military

Service start date

Have you ever been a member of the United Brotherhood of Carpenters (UBC)*

YESNO

Do you currently work for a signatory contractor*

YESNO

If yes, who

You are physically able to perform the work of a Millwright, which may include: Climbing and working from heights, on scaffolds, in confined spaces and underground.Lifting a minimum of 50 pounds. Performing repetitive motions Using a wide array of precision tools, such as Vernier calipers, micrometers, dial indicators, levels, gauge blocks, and optical laser alignment tooling used for standards of accuracy. Working under conditions of inclement weather, including rain, snow, cold, heat and direct sunlight. Standing and stooping for prolonged periods of time.*

YESNO

Must attend all related instruction classroom training as required to complete the apprenticeship program.*

YESNO

Why are you interested in applying for membership?*

Briefly describe the work you think is involved in this trade?*

List any trade skills, knowledge, certifications, etc., that you may have related to this/these trades:

Employer 1*

Start Date*

Date

End Date*

Date

Contact Person

Phone

Reason for leaving

Employer 2

Start Date

Date

End Date

Date

Contact Person

Phone

Reason for leaving

Employer 3

Start Date

Date

End Date

Date

Contact Person

Phone

Reason for leaving

Millwright Local 1163 is committed to equal opportunity for all applicants. The recruitment, selection, employment, and training of apprentices during their apprenticeship, shall be without discrimination because of race, color, religion, national origin, sex, or age - except the applicant must be 18 years of age. We respectfully request that you return this form along with your completed application form for apprenticeship.

The information, voluntarily provided below, is simply for equal employment opportunity commission (EEOC) purposes. This information will assist us in our efforts to provide accurate information in compliance with EEOC regulations and requirements.

Race

Are you of Hispanic or Latino Heritage

YESNO

How did you hear about us?

Completeness and accuracy of information: I certify that all of the statements and information given now or hereafter given by me, in support of my application for apprenticeship, is true and complete to the best of my knowledge.I understand that any false or misleading information will disqualify me from consideration for Membership/ Apprenticeship or subject me to immediate dismissal from the apprenticeship program at any time throughout my apprenticeship.

Authorization and release of information: I authorize Millwright Local 1163 to verify any of the information given, during the application process, with appropriate individuals, companies, organizations, or agencies and I authorize them to release such information as required, including my prior disciplinary record and drug test results, without any obligation to give me written notice of disclosure. I hereby release the Millwright local 1163 from any liability whatsoever as a result of such inquiries and disclosures. A photocopy of or other electronic reproduction of this authorization is binding and may be relied upon.

I acknowledge that I have read, understood, and accepted the above statement in its entirety, and have had the opportunity to ask questions regarding any aspect of this application and that I accept the above terms.

Signature*

Date*

Date

Millwright local 1163 Application

Please fill out the application below and we will be in contact with you about the next steps forward.

APPLICANT INFORMATION

MILITARY SERVICE

ADDITIONAL INFORMATION

EMPLOYMENT HISTORY

APPLICATION EEOC SUPPLEMENTAL INFORMATION FORM

PLEASE COMPLETE THE FOLLOWING

DISCLAIMER AND SIGNATURE