REASONABLE ACCOMMODATION NOTICE

To assure safe working conditions for all associates, we must be notified if have a physical or mental condition which may limit your ability to safely and effectively perform your job. Please answer the following questions:

Do you have any physical or mental conditions which may limit your ability to perform your job?

Yes

If the answer is YES, please do not identify the particular condition you have, simply describe what reasonable accommodation could be made to enable you to safely perform the essential function for your job:

The following are physical requirements, statements and questions pertaining only to essential job functions to general industrial job(s) you're applying for:

You must be able to perform the following functions or tasks: + Work a 10-hour shift, if required + Stand for extended periods throughout the day + Bend stoop regularly during this shift + Walk an extended distance + Lift and Carry over 30 pounds regularly during the shift + Lift and/or carry over 50 pounds or more if required during the shift + Lift and carry over 50 pounds or more if required during the shift + Work around dust and wear respirator, if required + Wear proper safety equipment (hard hats, goggles, back support, hair nets, etc) + Reach over your head with 10-30 pound loads regularly during your shift + Read, understand, and follow safety data sheets + Take direction and apply at a later time + Report to work every day, on time, without excuses, on and scheduled basis.

By signing below, I certify that I can perform the above noted essential functions, with or without reasonable accommodation(s)

Employee's Signature (Print full-name as signature)

Date Signed

YYYY

REASONABLE ACCOMMODATION NOTICE

Positions available