Application Form – WS Energy Services

“This Company” is an Equal Opportunity Employer and does not consider race, color, sex, age, disability, religion, national origin or veteran status as a factor in the election for employment.

Application

The applicant understands that the satisfactory completion of this evaluation period in no way constitutes an obligation by the Company to continue his/her employment, and that all employees are subject to termination with or without cause as determined solely by the company in its best interest. This application is considered active for sixty (60) days.

How did you hear of this opening?

Employee Referral: EE

Name

Walk-In

Other – Specify

DOT

Yes No

PERSONAL INFORMATION (Please Print or Type)

Last Name:

First Name:

Middle:

Physical Address:

City:

State:

Zip:

Mailing Address:

City:

State:

Zip:

Phone No.

Email:

Driver’s License No.

State:

Expiration Date

Class

Position Applied For:

Date Available:

Pay Requirement:

Are you employed now?

Yes No

May we contact your current employer?

Yes No

Have you ever been employed by any affiliated company of the Company?

Yes No

If so, what company?

Have you ever been convicted of a felony? (Conviction is not an automatic bar to employment)

Yes No

Have you ever had a positive drug or alcohol result from a previous employer?

Yes No

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?

Yes No

Do you have an active Non – Compete?

Yes No

If yes please provide a HR with a copy

Do you have or plan on having a full time or part time second job?

Yes No

If yes please provide details to HR

Did you serve in the U.S. Armed Forces?

Yes No

If yes, what branch?

In case of emergency, notify:

Phone Number:

EDUCATION

NAME AND LOCATION OF SCHOOL

YEARS ATTENDED

For High School and Above

ELEMENTARY

DID YOU GRADUATE?

MAJOR COURSES

HIGH SCHOOL

Yes No

COLLEGE

Yes No

TRADE, BUSINESS OR TECH SCHOOL

Yes No

JOB SPECIFIC TRAINING

CPR/First Aid

PEC

OSHA 30

EMPLOYMENT HISTORY (Complete even if resume’ is attached)

Give a complete record of all employment, including military, and reasons for periods unemployed. Start with the most recent. Applicants must list ALL employers within the previous ten (10) years- additional listing(s) to be recorded on the following page. If you have served in the armed forces, please attach a copy of your DD214.

Present or Last Employment First

Company’s Name, Address & Telephone Number

Last Salary, Position(s) Held & Supervisor(s)

Check One (1) and State Reason for Leaving

From Month:

From Year:

Company

Salary($)

Per

Ld. Off

Dischg.

Resign.

To Month:

To Year:

Address

Phone No.

Position

Reason for leaving:

City, State & Zip

Supervisor

Was the job designated as a safety sensitive job subject to alcohol and controlled substancetesting requirements as required by 49 CFR Part 40?

Yes No

Were you subject to the FMCSR regulations at any time during your last three (3) years of employment?

Yes No

ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON

From Month:

From Year:

Company

Salary($)

Per

Ld. Off

Dischg.

Resign.

To Month:

To Year:

Address

Phone No.

Position

Reason for leaving:

City, State & Zip

Supervisor

Was the job designated as a safety sensitive job subject to alcohol and controlled substancetesting requirements as required by 49 CFR Part 40?

Yes No

Were you subject to the FMCSR regulations at any time during your last three (3) years of employment?

Yes No

ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON

From Month:

From Year:

Company

Salary($)

Per

Ld. Off

Dischg.

Resign.

To Month:

To Year:

Address

Phone No.

Position

Reason for leaving:

City, State & Zip

Supervisor

Was the job designated as a safety sensitive job subject to alcohol and controlled substancetesting requirements as required by 49 CFR Part 40?

Yes No

Were you subject to the FMCSR regulations at any time during your last three (3) years of employment?

Yes No

ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON

From Month:

From Year:

Company

Salary($)

Per

Ld. Off

Dischg.

Resign.

To Month:

To Year:

Address

Phone No.

Position

Reason for leaving:

City, State & Zip

Supervisor

Was the job designated as a safety sensitive job subject to alcohol and controlled substancetesting requirements as required by 49 CFR Part 40?

Yes No

Were you subject to the FMCSR regulations at any time during your last three (3) years of employment?

Yes No

ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON

From Month:

From Year:

Company

Salary($)

Per

Ld. Off

Dischg.

Resign.

To Month:

To Year:

Address

Phone No.

Position

Reason for leaving:

City, State & Zip

Supervisor

Was the job designated as a safety sensitive job subject to alcohol and controlled substancetesting requirements as required by 49 CFR Part 40?

Yes No

Were you subject to the FMCSR regulations at any time during your last three (3) years of employment?

Yes No

ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON

From Month:

From Year:

Company

Salary($)

Per

Ld. Off

Dischg.

Resign.

To Month:

To Year:

Address

Phone No.

Position

Reason for leaving:

City, State & Zip

Supervisor

Was the job designated as a safety sensitive job subject to alcohol and controlled substancetesting requirements as required by 49 CFR Part 40?

Yes No

Were you subject to the FMCSR regulations at any time during your last three (3) years of employment?

Yes No

ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON

From Month:

From Year:

Company

Salary($)

Per

Ld. Off

Dischg.

Resign.

To Month:

To Year:

Address

Phone No.

Position

Reason for leaving:

City, State & Zip

Supervisor

Was the job designated as a safety sensitive job subject to alcohol and controlled substancetesting requirements as required by 49 CFR Part 40?

Yes No

Were you subject to the FMCSR regulations at any time during your last three (3) years of employment?

Yes No

ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON

TO BE READ AND SIGNED BY APPLICANT

authorize you to make sure investigations and inquiries to my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.

“I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to:

Review information provided by current/previous employers.
Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and
Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.”

DATE

APPLICANT'S SIGNATURE

This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge.

DATE

APPLICANT'S SIGNATURE

Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.

THIS SECTION MUST BE COMPLETED BY ALL APPLICANTS

This following requested information is in accordance with 49 CFR Parts 382.413, 391.21 and 391.23 of the Federal Motor Carrier Regulations for the Federal Highway Department. Prior employers may be contacted, for the purpose of investigating applicant’s background as required by 49 CFR 391.23.

Name First

Middle

Maiden

Last

Social Security Number:

Date of Birth:

Driver’s License #:

State:

Expiration Date:

Endorsement(s):

Previous Three Years Residency

(Street)

(City)

(State & Zip)

# Years

(City)

(Street)

# Years

(Street)

(City)

(State & Zip)

# Years

DRIVING EXPERIENCE

CLASS OF EQUIPMENT

TYPE OF EQUIPMENT (VAN, TANK FLAT, ETC)

DATE FROM

DATE TO

APPROX. NO. OF MILES (TOTAL)

STRAIGHT TRUCK

TRACTOR AND SEMI-TRAILER

TRACTOR-TWO TRAILERS

OTHER

List all motor vehicle accidents during the past 3 years:

Date of Accident

Nature of Violation/Accident (speeding, head-on etc.)

Fatalities/Injuries

At Fault

Yes No

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)

DATE CONVICTED (month/year)

VIOLATION

STATE OF VIOLATION

PENALTY (forfeited bond, collateral and/or points)

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?

Yes No

B. Has any license you held ever been suspended or revoked?

Yes No

If you answered yes to any of the above, give details.

C. Have you ever tested positive, or refused to test, on any pre-employment drug test Administered by an employer to which you app for, but did not obtain, safety Sensitive transportation work covered by DOT agency drug testing rules during the past two years?

Yes No

D. If you answered yes, can you provide/ obtain proof that you’ve successfully completed the DOT return-to-duty requirements?

Yes No

E. Have you ever been convicted of a felony?

Yes No

EMPLOYMENT STATEMENT

In completing and submitting this application, I understand and agree:

That I am applying for a job as an employee-at-will. That the falsification or concealment of facts, or failure to provide complete and correct information during this application process can result in discharge when discovered.

I hereby certify by my signature below that this application was completed by me, and that all information provided in this application is true and complete to the best of my knowledge. I further agree to hold any and all parties harmless for the disclosure of any information pertaining to my application for employment.

I consent to all of the following pre-employment processes, which are required by the Company, and I further understand that the offer of employment is contingent upon my successfully completing all pre-employment testing.

Motor Vehicle Report, Previous Employer Drug & Alcohol History (DOT applicants, 49 CFR 382.413), Drug Screen, Physical Examination & Functional Capacity (physical demand abilities), Alcohol Screen, Background Check

I agree and understand that this application for employment in no way obligates the employer to employ the applicant.

Print Name

Signature

Social Security Number

Date

Date of Birth

Driver’s License Number & State

Voluntary Self-Identification

(EEO-1 changes, updated information needed for EEO-1 reporting purposes only)

The Equal Employment Opportunity Commission (EEOC) requires organizations with 100 or more employees to complete an EEO-1 report each year. We are asking employees to complete this self-identification sheet below so that we can properly update our records according to report requirements.

Completion of this data is voluntary and will not affect your opportunity for employment or terms or conditions of employment. This form will be used for EEO-1 reporting purposes only and will be kept separate from all other personnel records and will only be accessed by Human Resources Department. Please return completed forms to the Human Resources Department.

Name:

Job Title:

Date completed:

GENDER:(Please check one of the options below)

Male Female

RACE/ETHNICITY:
(Please check one of the descriptions below corresponding to the ethnic group with which you identify.)

Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. White (Not Hispanic or Latino) – A person having origins in any of the original peoples of Europe, the Middle East or North Africa. Black or African American (Not Hispanic or Latino) – A person having origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) – A person having origins in any of the peoples of Hawaii, Guam, Samoa or other Pacific Islands. Asian (Not Hispanic or Latino) – A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam. American Indian or Alaska Native (Not Hispanic or Latino) – A person having origins in any of the original peoples of North and South America (including Central America) and who maintain tribal affiliation or community attachment. Two or More Races -All persons who identify with more than one of the above six races.

PLEASE RETURN FORM TO HUMAN RESOURCES DEPARTMENT. Thank you for your participation.

Background Authorization

WS Energy Services

IPT

, hereby authorize “The Company” to investigate my background and qualifications for purposes of evaluating for the position for which I am applying. I understand that “The Company” will utilize an outside firm or firms to assist in checking such information, and I specifically authorize such an investigation by information services and outside entities of the company’s choice. I also understand that I may withhold my permission and that in such case, no investigation will be done, and my application for employment will not be processed further.

Employee Signature:

Date:

Employee’s Name Printed: