GEIR FIELD POSITION EMPLOYMENT APPLICATION

Global Environmental And Industrial Response, LLC is an equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Should an applicant need reasonable accommodation in the application process, he or she should contact a company representative.
Date of Application:

MonthDayYear
Company:
Address:
City:
State:
Zip:
33610
TO BE READ AND SIGNED BY APPLICANT

I authorize you to make such investigations and inquiries of 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 liabiloity 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 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 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.

SIGNATURE: _______________________________________ DATE: ________________
FOR COMPANY USE ONLY

---------------------------------------- PROCESS RECORD ----------------------------------------

APPLICANT: _____ POSITION OFFERED ____ APPLICANT REJECTED
DATE OF HIRE: ___________________ OFFICE ASSIGNED: ___________________
SIGNATURE OF INTERVIEWER(S): _______________________________________

-------------------------------- TERMINATION OF EMPLOYMENT --------------------------------

DATE TERMINATED: ______________________

REASON: ____ VOLUNTARY QUIT ____ INVOLUNTARY TERMINATION ____ OTHER

REHIRE STATUS: ____ YES ____ NO

OFFICE RELEASED FROM: _____________________________________________

MANAGER RELEASING EMPLOYEE FROM POSITION: ________________________
Applicant Information
Full Name*

First NameMiddle NameLast Name
Current Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number:*

Area CodePhone Number
E-mail*
Employment Position
Position(s) applying for:
How did you hear about this position?
On what date can you start working if you are hired?

MonthDayYear
Desired Start Date
Personal Information
Have you ever applied to or worked for Global Environmental and Industrial Response, LLC before?

YesNo
If yes, when?

MonthDayYear
Date previously applied
Do you have any friends, relatives, or acquaintances working for Global Environmentaland Industrial Response, LLC

YesNo
If yes, state Name:
Employee
Relationship
Are you 18 years of age or older?

YesNo
Are you a U.S. citizen or approved to work in the United States?

YesNo
Will you consent to a mandatory controlled substance test?

YesNo
Job Skills/Qualifications
Please list below the skills and qualifications you possess for the position for which you are applying:
(Note: Global Environmental and Industrial Response, LLC complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. )
Education and Training
High School:
Location:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Degree Earned:
College/University:
Location:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Degree Earned:
Vocational School/ Training:
Location:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Degree Earned:
Are you a member of the Armed Services?

YesNo
What branch of the military did you enlist?
What was your military rank when discharged?
How many years did you serve in the military?
What military skills do you possess that would be an asset for this position?
Previous Employment
Employer Name:
Job Title:
Supervisor Name:
Employer Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number:

Area CodePhone Number
Date From:
Date To:
Reason for Leaving:
Previous Employer Name #2:
Job Title:
Supervisor Name:
Employer Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number:

Area CodePhone Number
Date From:
Date To:
Reason for Leaving:
Previous Employer Name #3:
Job Title:
Supervisor Name:
Employer Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number:

Area CodePhone Number
Date From:
Date To:
Reason for Leaving:
References

Please provide 3 personal and professional reference(s) below:
Reference Name #1:

First NameLast Name
Reference Phone Number #1:

Area CodePhone Number
Reference Name #2:

First NameLast Name
Reference Phone Number #2:

Area CodePhone Number
Reference Name #3:

First NameLast Name
Reference Phone Number #3:

Area CodePhone Number
TO BE READ AND SIGNED BY APPLICANT

AT-WILL EMPLOYMENT

The relationship between you and the Global Environmental and Industrial Response, LLC is referred to as "employment at will." This means that your employment can be terminated at any time for any reason, with or without cause, with or without notice, by you or the Global Environmental and Industrial

Response, LLC. No representative of Global Environmental and Industrial Response, LLC has authority to enter into any agreement contrary to the foregoing "employment at will" relationship. You understand that your employment is "at will," and that you acknowledge that no oral or written statements or representations regarding your employment can alter your at-will employment status, except for a written statement signed by you and either our Executive Vice-President/Chief Operations Officer or the Company's President.

SIGNATURE: _______________________________________ DATE: ________________
Should be Empty:

Applicant Information

Employment Position

Personal Information

Job Skills/Qualifications

Education and Training

Previous Employment

References