Rival Well Services, INC. Employment Application

Rival Well Services, INC.

EMPLOYMENT APPLICATION
We are an equal opportunity employer. It is our policy to comply with all applicable state and federal laws prohibiting discrimination in employment, based on race, age, color, sex, religion, national origin, disability, veteran's status or other protected classification. We only hire individuals authorized for employment in the United States.
Todays Date
MonthDayYear
Date
Name
First*
Middle Initial
Last*
Suffix
Address
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Information
Home Phone*
Cell Phone*
Email*
example@example.com
Other Information
Soc. Sec. No.*
XXX-XX-XXXX
Are you authorized to work in the United States?*

YESNO
Are you over 18 years old?*

YESNO
Have you worked for our company before?*

YESNO
If YES, please include dates:

MonthDayYear
Start Date
MonthDayYear
End Date
Description of Duties:
Reason For Leaving:
Are you Related to any Employees of our Company?*

YESNO
If YES, Please state name and relation:
Position(s) Applying For:*
Preferred Shift*
Days or Nights
Preferred Shift*

Part-TimeFull-Time
Are there any hours, shifts or days that you will not be able to work?*

YESNO
If YES, Please explain:
Are you willing to work any overtime?*

YESNO
Are you willing to travel?*

YESNO
INSURANCE

Please list your previous health insurance carriers:
EDUCATION
High School*
Name/Location of School
Graduated?*

YESNO
College/University
Name/Location of School
Graduated?

YESNO
Major
Diploma/Degree
Other
Name/Location of School
Graduated?

YESNO
Diploma/Degree
WORK HISTORY

Current or Most Recent Employer Information:
Employer Name:*
Employer Address:
Employer Telephone:*
Name and Title of Supervisor:
Description of Duties:*
Start Date*

MonthDayYear
Date
Start Position*
Start Salary*
End Date*

MonthDayYear
Date
End Position*
End Salary*
Reason For Leaving:*
Previous Employer

Previous Employer Information:
Employer Name:
Employer Address:
Employer Telephone:
Name and Title of Supervisor:
Description of Duties:
Start Date

MonthDayYear
Date
Start Position
Start Salary
End Date

MonthDayYear
Date
End Position
End Salary
Reason For Leaving:
Previous Employer

Previous Employer Information:
Employer Name:
Employer Address:
Employer Telephone:
Name and Title of Supervisor:
Description of Duties:
Start Date

MonthDayYear
Date
Start Position
Start Salary
End Date

MonthDayYear
Date
End Position
End Salary
Reason For Leaving:
In addition to your work history, what other experiences, skills or qualifications would be beneficial to our Company?*
Authorization To Release Information
As an applicant for a position and/or a current employee with the Company, I have been asked to furnish information for use in reviewing my background and qualifications. In this connection, I hereby authorize a thorough investigation to be made of my past and present work, character, education, military, criminal record, general reputation, whichever may be applicable to ascertain any and all information, excluding medical, information, which may be pertinent to my employment qualifications.

I authorize you to provide any and all information, whether such information is of record or not. I hereby release you and all persons, firms, agencies or companies from any damages resulting from furnishing such information.
Printed Name*
Signature*

Clear
Date*

MonthDayYear
Date
Applicant's Certification and Agreement
I hereby affirm that all the information provided by me in connection with my application, whether on this document or not, is true and complete. I understand that any misstatement, falsification or omission of information shall be grounds for refusal to hire or immediate dismissal/termination. I authorize the Company to make an investigation of any of the facts set forth in the application. I understand this application is not a contract of employment, and that employment at the Company is "at will", which means that either I or the Company can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statute. All employment is continued on that basis. I understand that no supervisor, manager or executive of the Company, other than the President, has any authority to alter the foregoing.
Printed Name*
Applicant's Signature*

Clear
Date*

MonthDayYear
Date
Please attach your resume, if available:

Cancelof
Should be Empty:

Rival Well Services, INC.

Todays Date

Name

Address

Contact Information

Other Information

INSURANCE

EDUCATION

WORK HISTORY

Previous Employer

Previous Employer

Authorization To Release Information

Applicant's Certification and Agreement