Personal Information:
Emergency Contact
Addresses for 3 Previous years
From:
To:
From:
To:
From:
To:
Employment History
Give a complete record of all employment for the past ten years, starting with the most recent job first. Any gaps in employment must be noted and verified.
Present or Last Employer:
From:
To:
From:
To:
From:
To:
Next Previous Employer:
From:
To:
Driving Experience
Equipment
From
To
Approximate # of Miles
List the states operated in for the past 5 years:
List any safe driving awards you have won and who you received them from:
*List ALL Certifications including Oil and Gas:
List all personal and commercial accidents for the past 3 years:
Dates
Nature of Accident
(Head On, Rear end, etc.)
Number of Fatalities
Number of
Injured
List all personal & commercial traffic convictions & forfeitures for the past 3 years: (other than parking violations)
Location
Date
Charge
Penalty
List all driver's licenses held for the past 3 years: (including current license)
State
License Number
Type
Endorsements
Exp. Date
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
Has any License, permit or privilege ever been suspended or revoked?
Have you ever been convicted of a felony?
Have you ever been convicted of a DUI/DWI?
Have you ever tested positive for any controlled substance or alcohol?
*IF YES, can you provide documentation proving you have completed necessary steps to return to work?
If the answer to any question above is yes, please explain in detail:
To be read and signed by applicant:
It is agreed and understood that any misrepresentations given, shall be considered an act of dishonesty and will be grounds for immediate disqualification.
It is agreed and understood that Eagle River Energy Services LLC, or their agents, may investigate the applicant's background, to ascertain any and all information of concern to applicant's record, whether same is of record or not and applicant releases employers and persons named herein, from all liability for any damages on account of their furnishing such information.
By signing below, applicant agrees to furnish such additional information and complete such examinations as may be required to complete their employment file
It is agreed and understood that if hired, the applicant will be placed into a ninety day probationary period, during which time, they may be disqualified without any recourse.
By signing below, I certify that this application was completed by me and that all entries on it and information in it, are true and complete, to the best of my knowledge.
