Employment Application

Name*

First NameLast Name

Social Security # 000*-00* -0000*

Date of Birth:*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone Number*

Please enter a valid phone number.

Home Phone Number

Please enter a valid phone number.

Email Address*

example@example.com

Why Do You Want to Work Here?

High School Name:

Name

Dates Attended

Month/Year

Diploma/Last Year Completed

High School Diploma

Year Finished

College

Name

Dates Attended

Year Started and FInished

Degree Earned

Degree/Diploma

Year Finished

Tech School

Name

Dates Attended

Month/Year Started and Finished

Degree Earned

Studied in...

Year Finished

Additional

Certifications, Trainings

Describe any professional licenses, certifications or registrations you have

Current Drivers License?*

YesSuspendedNO

C.D.L?*

YesNO

Medical Card Current?

YesNo

Name*

First NameLast Name

Relationship*

Phone*

Address

1234 Street Name, City, State, Zip Code

1) Current or Most Recent Employer:*

Address*

1234 Street Name, City, State, Zip Code

Phone*

Please enter a valid phone number.

Fax:

Please enter a valid number.

Average Hours Per Week:*

Hire Date*

Date

Quit Date*

Date

Job Title(s)*

Start Rate of Pay: $ . Ending Rate of Pay: $.

Supervisor:*

First NameLast Name

Supervisor Contact Number:*

Please enter a valid phone number.

Responsibilities:*

Reason(s) for leaving:*

Did you give a two-week notice? (if quit)

YesNo

Were you subject to the FMCSR's (Federal Motor Carrier Safety Regulations) while employed?

YesNo

Was your job designated as a Safety-Sensitive Function in any DOT-regulated mode subject to the Drug and Alcohol Testing Requirements of 49 CFR Part 40?

YesNo

2) Previous Employer:

Address:

1234 Street Name, City, State, Zip Code

Phone:

Fax:

Please enter a valid phone number.

Average Hours Per Week:

Hire Date:

Date

Quit Date:

Date

Job Title(s):

Start Rate of Pay: $. Ending Rate of Pay: blank .

Supervisor:

First NameLast Name

Supervisor Contact Number:

Please enter a valid phone number.

Responsibilities:

Reason(s) for leaving:

Did you give a two-weeks notice? (if quit)

YesNo

Were you subject to the FMCSR's (Federal Motor Carrier Safety Regulations) while employed?

YesNo

Was your job designated as a Safety-Sensitive Function in any DOT-regulated mode subject to the Drug and Alcohol Testing Requirements of 49 CFR Part 40?

YesNo

3) Previous Employer:

Address:

1234 Street Name, City, State, Zip Code

Phone

Fax:

Average Hours Per Week:

Hire Date:

Date

Quit Date:

Date

Job Title(s):

Start Rate of Pay: blanks . Ending Rate of Pay: blank .

Supervisor:

First NameLast Name

Supervisor Contact Number:

Please enter a valid phone number.

Responsibilities:

Reason(s) for leaving:

Did you give a two-week notice? (if quit)

YesNo

Were you subject to the FMCSR's (Federal Motor Carrier Safety Regulations) while employed?

YesNo

Was your job designated as a Safety-Sensitive Function in any DOT-regulated mode subject to the Drug and Alcohol Testing Requirements of 49 CFR Part 40?

YesNo

Have you ever committed a felony or a first-degree misdemeanor?*

YesNo

If "yes", describe in detail:

Where?

Date

List two professional references (current or previous boss, supervisor, etc) & their contact info:

1) Name:*

First NameLast Name

Phone Number:*

Please enter a valid phone number.

Email:

example@example.com

2) Name:*

First NameLast Name

Phone Number:*

Please enter a valid phone number.

Email:

example@example.com

State:*

If not applicable put N/A

License Number:*

If not applicable put N/A

Experation Date:

Date

Endorsements(s):*

Traffic Convictions and Forfeitures for the past three years (Other than Parking Violations)

Location, Date, Charge, Penalty

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

YesNo

Has any license, permit or privilege ever been suspended or revoked?*

YesNo

If you answered yes to either of the two previous questions, please give details:

Straight Truck:

Type of Equipment, Dates From-To, Approx. Number of Miles TTL

Tractor Trailer:

Type of Equipment, Dates From-To, Approx. Number of Miles TTL

Other:

Type of Equipment, Dates From-To, Approx. Number of Miles TTL

Last Accident:

Date, Nature of the Accident (Head-on, rear-end, upset, Etc.) Fatality, Injury, Non-Injury

Next Previous

Date, Nature of the Accident (Head-on, rear-end, upset, Etc.) Fatality, Injury, Non-Injury

Next Previous

Date, Nature of the Accident (Head-on, rear-end, upset, Etc.) Fatality, Injury, Non-Injury

What position are you applying for?

Desired Rate of Pay:

Desired Benefits

Willing to work overtime?

YesNo

Willing to work occasional weekends?

YesNo

Are you a veteran?

YesNo

Institution Name

Duty/specialized training

Additional Skills

As part of our procedure for processing your employment application, your personal and employment references may be checked. If you have misrepresented or omitted any facts on this application, and are subsequently hired, you may be discharged from your job. You may make a written request for information derived from the checking of your references. As necessary for employment, you may be required to: supply your birth certificate or other proof of authorization to work in the United States, have a physical examination and/or a drug test, or to sign a conflict of interest agreement.

A company safety policy and company drug policy must be signed prior to employment, and you will be required to abide by their terms.

I understand and agree to the information shown above. This certifies that this application was completed by me, and that all entries on it are true and complete to the best of my knowledge. I authorize you to make such investigations and inquiries of my personal, employment, 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, 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.

Signature of Applicant

Date

Questions?

EMAIL: contact@Lighthousedrilling.com

MAIL: PO BOX 1118 El Dorado, KS 67042

OFFICE: 1919 W. Central Ave. El Dorado, KS 67042

SHOP: 838 SW Purity Springs Rd. El Dorado, KS 67042

EMPLOYMENT APPLICATION

PERSONAL INFORMATION:

EDUCATION:

LICENSURE, REGISTRATIONS, CERTIFICATIONS:

Primary Emergency Contact

EMPLOYMENT HISTORY (3-Year Minimum Required)

BACKGROUND INFORMATION:

REFRENCES:

DRIVER'S EXPERIENCE AND QUALIFICATION:

DRIVING EXPERIENCE:

ACCIDENT RECORD FOR THE PAST THREE YEARS OR MORE:

OTHER INFORMATION: