APPLICATION FOR EMPLOYMENT

Date of application*

MonthDayYear

Position applying for*

Full name*

First NameLast Name

Current address*

Street Address

Street Address Line 2

CityProvince

Postal Code

Phone number*

Email*

Available start date*

Are you legally permitted to work in Canada?*

West-Can Seal Coating Inc. provides seasonal employment between the months of May to October. During this period do you have any pre-arranged time commitments that would require you to be absend during the upcoming season?

Yes or No*

If yes please provide date(s)

Have you previously worked for West-Can Seal Coating Inc.*

If yes please provide date(s) and position

Are you willing to work away from home for long periods of time*

Are you aware of any reason why you would fail a medical examination or drug screening?*

How many years of road construction experience do you have?*

How many years of commercial driving experience do you have?*

Physical exertion and/or manual dexterity may be required. Examples: bending, twisting, climbing, lifting, shoveling, carrying, repetative hand motion, hand/eye coordintion, remaining in a stationary position for extended periods of time, working in different climates and working on uneven surfaces.

Is there anything that would prevent you from carrying out these activities or working in these conditions?

If you answered yes, will you require accommodations

Please provide information regarding the accommodations required

CURRENT OR MOST RECENT EMPLOYMENT

Name of employer*

Phone number*

Position held*

Address*

City and Province

Start date*

End date*

Reason for leaving*

I authorize West-Can Seal Coating Inc. to contact the above employer*

Supervisors name

Name of employer

Phone number

Position held

Address

City and Province

Start date

End date

Reason for leaving

I authorize West-Can Seal Coating Inc. to contact the above employer

Supervisors name

Name of employer

Phone number

Position held

Address

City and Province

Start date

End date

Reason for leaving

I authorize West-Can Seal Coating Inc. to contact the above employer

Supervisors name

Certificate name

Where certificate was obtained

Date certificate was obtained

Expiry date of certificate

Certificate name

Where certificate was obtained

Date certificate was obtained

Expiry date of certificate

Certificate name

Where certificate was obtained

Date certificate was obtained

Expiry date of certificate

Please note: All successful candidates are required to submit a 5 year commercial drivers abstract. The abstract is required prior to the start date and must be dated no earlier than one month prior to the start date.

In which province do you currently hold a valid drivers license?

Drivers license number

Class of drivers license

Driving

Operating

List any other equipment or driving experience not listed above

None

Date

Location/Prov

Was the collision preventable?

Collision type

Brief description:

Date

Location/Prov

Was the collision preventable?

Collision type

Brief description

Date

Location/Prov

Was the collision preventable?

Collision type

Brief description

None

Date of conviction

Date

Province of conviction

Type of offense

Brief description

Date of conviction

Date

Province of conviction

Type of offense

Brief description

Date of conviction

Date

Province of conviction

Type of offense

Brief description

None

Date of conviction

Date

Province of conviction

Type of offense

Brief description

Date of conviction

Date

Province of conviction

Type of offense

Brief description

Date of conviction

Date

Province of conviction

Type of offense

Brief description

ACKNOWLEDGEMENT

I declare that all of the information supplied by me on this application is true and complete to the best of my knowledge. I understasnd that a false statement may disqualify me from employment or may cause my dismissal.

I hereby acknowledge that any offer of employment is conditional upon the passing of a drug and alcohol test as required by the company which will be administered by a Company approved collection facility.

I further acknowledge that any offer of employment may be contingent on a job related medical examination if the Company sees fit. I understand that failure to meet the Company's standards pertaining to a medical examination is sufficient cause to disqualify me from employment or may be cause for dismissal.

Should I refuse the required drug and alcohol testing or refuse medical examination (if required) I acknowledge that such refusal shall be deemed a withdrawl of the above application for employment.

Authorization to Release Information

In making this application for employment, I authorize the offices or employees of the above noted former employers to release to the Company a complete history of my previous employment with their organization. I acknowledge that the information that may be requested may pertain to wages, tenure, reason(s) for termination and character and work ethic during the course of my employment.

I further authorize any law enforcement agency, administrator, provincial agency, educational institution or private information bureau that has any record or knowleddge of my employment history, motor vehicle operation history, criminal record, education, credit or other history records to provide that information upon receipt of this signed release. A telephone facsimile (fax) or photographic copy of the authorization shall be considered as valid as the original. I release all parties from all liablity for any damage that may result from furnishing such information to West-Can Seal Coating inc.

All personal information submitted on this application is confidential and I hereby consent to the collection and use of such personal information for employnent purposes, specifically where such information is necessary to establish, manage or terminate my employment with West-Can Seal Coating Inc.

Certification

I certify that the information contained in this application or any other form related to my employment is true and complete to the best of my knowledge. I understand that false or incomplete statements shall be grounds for disqualification or dismissal from employment when revealed.

Signature*

Date*

APPLICATION FOR EMPLOYMENT

Personal Information

EMPLOYMENT HISTORY

CERTIFICATES

DRIVERS INFORMATION

PREVIOUS DRIVING OR OPERATING EXPERIENCE

COLLISIONS

DRIVING CONVICTIONS

COMMERCIAL VIOLATIONS