A&W Water Service, Inc. - Employment Application DOT

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Conditions of employment are stated at the end of this form. Please read carefully before you sign this application.
Application must be completed in full. Job applications are considered active for 60 days afterwhich the applicant must reapply for furthur consideration.

PERSONAL

Instructions to Applicant
Please answer all questions. Do not leave any items blank.

Position applying for:

First Name

Middle Name

Last Name

Home Phone Number

Message Phone Number

If no phone, how may we contact you?

Birthdate (MM/DD/YYYY)

Social Security Number

Current and Previous Addresses:

Have you ever worked for this company or any divisions of Complete Production Services before? Yes No

If yes, give dates:

Location

Have you ever applied to this company or any divisions of Complete Production Services before? Yes No

If yes, give dates:

Location

How were you referred?

GENERAL INFORMATION

Are you under the age of 18?

Yes No

If under age 18, can you supply working papers? Yes No

Only U.S. citizens or aliens who have a legal right to work in the U.S. are eligible for employment. Can you, upon employment provide genuine documentation establishing your identity and eligibility to be legally employed in the United States? Yes No

Have you ever been convicted of a felony? Yes No

(A conviction record will not necessarily be a bar to employment. Factors such as job relations, age and time of offense, seriousness and nature of violation and rehabilitation will be taken into account).
If yes, please explain:

Have you ever been discharged from any employment or asked to resign? Yes No

If yes, please explain:

Can you perform the essential functions of the position for which you have applied ? Yes No

If no, please explain:

JOB INTERESTS

Please state type of work preferred.

Position(s) Desired

Date available for work

Salary Desired

Geographical Preference(s)

Willing to travel? Yes No

Are you available to work (please check all that apply)

Full-Time	Temporary	Overtime, if required
Part-Time	Summer Only	Weekends, if required

EMPLOYMENT HISTORY

BEGIN WITH YOUR MOST RECENT EMPLOYMENT AND CONTINUE WITH ALL PAST EMPLOYMENT FOR THE LAST 3 YEARS.
All driver applicants driving in interstate commerce must provide the following information on all employers during the past three years. List complete mailing address, street number, city, state and zip. Applicants driving a commercial vehicle* in intrastate or interstate commerce shall also provide an additional 7 years information on those employers for whom the applicant operated a vehicle. List employers in reverse order starting with the most recent.

Job 1: From To

Starting Salary

Employer

Ending Salary

Type of Business

Job Title

Describe your Job Duties

Reason for Leaving

Name and Title of Immediate Supervisor

May we contact employer? Yes No

Were you subject to the FMCSRs* while employed here? Yes No

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? Yes No

Explain any period between jobs

Job 2: From To

Starting Salary

Employer

Ending Salary

Type of Business

Job Title

Describe your Job Duties

Reason for Leaving

Name and Title of Immediate Supervisor

May we contact employer? Yes No

Were you subject to the FMCSRs* while employed here? Yes No

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? Yes No

Explain any period between jobs

Job 3: From To

Starting Salary

Employer

Ending Salary

Type of Business

Job Title

Describe your Job Duties

Reason for Leaving

Name and Title of Immediate Supervisor

May we contact employer? Yes No

Were you subject to the FMCSRs* while employed here? Yes No

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? Yes No

Explain any period between jobs

Job 4: From To

Starting Salary

Employer

Ending Salary

Type of Business

Job Title

Describe your Job Duties

Reason for Leaving

Name and Title of Immediate Supervisor

May we contact employer? Yes No

Were you subject to the FMCSRs* while employed here? Yes No

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? Yes No

Explain any period between jobs

*Includes vehicles having a CVWR of 26,001lbs. or more, or any size vehicle used to transport hazardous materials in a quantity require placarding.
**The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone who operates a motor vehicle on a highway to interstate commerce to transport passenders or property when the vehicle: (1) has a GVWR or weighs 10,001 pounds or more. (2) is designed or used to transport nine or more passengers. or (3) is of any size, used to transport hazardous materials in a quantity requiring placarding.

EDUCATION

Type of School	Name & Address of School	Major Subject	Last Year Attended	Graduated	Degree
High School				Yes No
College				Yes No
College				Yes No
Graduate School				Yes No
Business, Trade, Other				Yes No

ADDITIONAL EXPERIENCE OR QUALIFICATIONS

List any other experience, skills or other qualifications including hobbies, which you believe should be considered in evaluating your qualifications for employment.

US MILITARY INFORMATION

Branch of Service

Rank at Discharge

Active Duty From:

Active Duty To:

Date of Final Discharge:

DRIVING INFORMATION

Accident Record for the past three years, if NONE, write NONE.

Date of Accident	Nature of Accident	Hazardous Mat'l Spill	# of Fatalities	# of People Injured

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No

B. Has a license, permit or privilege ever been suspended or revoked? Yes No

If the answers to A or B "YES", give details:

List special courses or training that will help you as a driver

List any Safe Driving Awards you hold and from whom

List any trucking experience that may help you in your work

List special equipment and types of trucks you have experience operating

REFERENCES

Name

Address

Phone

Relationship

Name

Address

Phone

Relationship

Name

Address

Phone

Relationship

NOTIFICATION AND AGREEMENT

I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE AND COMPLETE, I UNDERSTAND THAT THE FALSIFICATION, MISREPRESENTATION OR OMISSION OF FACT ON THIS APPLICATION (OR ANY OTHER ACCOMPANYING OR REQUIRED DOCUMENTS) WILL BE CAUSE FOR DENIAL OF EMPLOYMENT OR IMMEDIATE TERMINATION OF EMPLOYMENT, REGARDLESS OF WHEN OR HOW DISCOVERED.

Questions regarding this statement should be directed to any employment interviewer before signing. The application will be given every consideration, but its receipt does not imply that the applicant will be employed.

It is the policy of the company to afford equal opportunity to all employees and applicants for employment without regard to age, race, religion, color, sex, national origin, marital status or pregnancy, and to afford equal opportunities to disabled veterans, veterans of the Vietnam era, and individuals with a disability, any and other characteristic protected by Federal, State or Local law.

I authorize the investigation of all statements and information contained in this application. I release from all liability anyone supplying such information and I also release the employer from all liability that might result from making an investigation.

I hereby certify that all of the facts and information listed on this employment application are true and complete. I understand that any false, incomplete or misleading information given by me on this application is sufficient cause for rejection of this application. I also understand and agree that any such false, incomplete or misleading information discovered on this application at any time after I am employed may result in dismissal.

If I am offered employment, I understand that such an offer will be conditioned upon satisfactory results of a background investigation and/or Company medical examination or inquiry, including a drug-screening test. I consent to the investigation, physical and drug test.

I hereby authorize the Company to investigate all statements contained in this application, to interview the references and previous employers listed in the application, and to obtain a report from a consumer-reporting agency to be used for employment purposes in accordance with the Fair Credit Reporting Act. I authorize the references and previous employers listed to give the Company all facts, opinions and evaluations concerning my previous employment and any other information they may have, personal or otherwise, and release all such information to the Company, including, but not limited to, any liability or invasion of privacy.

If I am applying for a position as a Driver within any division of Complete Production Services, I understand that information I provide regarding current and/or previous employers may be used, and those employers 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 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.

In consideration of my employment, I agree to conform to the company's rules and regulations, and I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company's option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice, at any time by the company.

I furthur understand and voluntarily agree as a condition of employment or my continued employment, tha I may be requested by the Company to submit to a urinalysis or other drug screen test and that my failure to take such test(s) when requested to do so or unsatisfactory test results will disqualify me from consideration for employment, or if I am then employed, may result in immediate dismissal.

I acknowledge that I have read and understand the above statements and hereby grant permission to confirm the information supplied on this application by me.

By checking this box I agree with the above statements.

Name

Date

A&W Water Service, Inc. - A Complete Energy Services Company