Employment Application Form Employment Application If you are human, leave this field blank. EMPLOYMENT APPLICATION Last Name * First Name * M.I. Date * Street Address * Apt. # / Unit City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ZIP Code * Phone Number * Other Phone Email Address * Position Applied For * Date Available * Desired Salary per Timeframe Type of Employment Desired? Full Time Part Time Seasonal Temporary Are you legally authorized to work in the United States? * Yes No Have you ever worked for Sure Shot Drilling or its associates? * Yes No Do you have a valid United States-issued Driver's License? * Yes No If YES, which State or Province? In the last three years, has your license been: Suspended Revoked Please explain: List any moving violations you have had in the past three years, please explain. Have you ever entered into a no contest plea, plead guilty or been convicted of a misdemeanor in the last 10 years? * Yes No If YES, please explain: Have you ever entered into a no contest plea, plead guilty or been convicted of a felony in the last 10 years? * Yes No If YES, please explain: Please Note that disclosure of misdemeanors or felonies will not automatically disqualify you from potential employment; however omissions, inaccuracies or false statements could result in a "no hire" situation. EDUCATION High School: High School Location: From: To: Years Completed: Degree: College: College Location: From: To: Years Completed: Degree: Other School: Other School Location: From: To: Years Completed: Degree: MILITARY SERVICE If you served in multiple branches, please click the "ADD" button below. Branch: From: To: Rank at Discharge: Type of Discharge: If other than "Honorable", please explain: Add Remove Prior Residences Last three years. If you need more room, click the "ADD" button below. Street Address City ST Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Months / Years Add Remove LICENSE EXPERIENCE / QUALIFICATIONS Driver's License Type State Issued License Number Expiration Date Add Remove DRIVING EXPERIENCE STRAIGHT TRUCK Type of Equipment (van, flat, etc.) Date From: Date To: Approx. Mileage TRACTOR / SEMI-TRAILER Type of Equipment (van, flat, etc.) Date From: Date To: Approx. Mileage TRACTOR / TWO-TRAILERS Type of Equipment (van, flat, etc.) Date From: Date To: Approx. Mileage OTHER Type of Equipment (van, flat, etc.) Date From: Date To: Approx. Mileage TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS Location: Date Charge: Penalty: Add Remove If you have NOT had any convictions or forfeitures in the past 3 years, check this box I have NOT had any convictions or forfeitures in the past 3 years If you have NOT had any convictions or forfeitures in the past 3 years, put your initials in this box Have you ever been denied a license, permit, or privilege to operate a motor vehicle? Yes No If yes, provide details: Has any license, permit or privilege ever been suspended or revoked? Yes No If yes, provide details: Have you ever tested positive or refused to be tested on a Pre‐Employment Drug Screen for an employer that you did not go to work for? Yes No If yes, give date and name of employer: ACCIDENT RECORD FOR THE PAST THREE YEARS Date Type of Accident (Head On, Rear End, etc.) Fatalities / Injuries / Damage Add Remove If you have not had any traffic convictions or forfeitures for the past 3 years, please put your initials in the box TO BE READ AND SIGNED BY APPLICANT I understand that a copy of my Motor Vehicle Record and the information in this application, including past employment information, will be used and that prior employers will be contacted for purposes of investigating my safety performance history information as required by paragraphs (d) and (e) of Part 391.23 of the Federal Motor Carrier Safety Regulations. I also understand that I have the following rights regarding the investigative information that will be provided to Sure Shot Drilling (SSD): 1) the right to review information provided by previous employers 2) the right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to Sure Shot Drilling; 3) the right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and I cannot agree on the accuracy of the information. In order to review previous employer-provided investigative information I must submit a written request to Sure Shot Drilling (SSD), which may be done at any time, including when applying, or as late as 30 days after being employed or being notified of denial of employment. SSD will provide this information to me within five business days of receiving my written request. If SSD has not yet received the requested information from the previous employer(s), then the five-business days deadline will begin when SSD receives the requested safety performance history information. If I have not arranged to pick up or receive the requested records within thirty (30) days of SSD making them available, SSD may consider me to have waived my request to review the records. I also understand that misrepresentation or omission of information or facts may results in my rejection or dismissal. This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge. Date * TYPE FULL NAME IN THE BOX BELOW TO ACKNOWLEDGE * PAST EMPLOYMENT (Include all employers for the past three years and any employment that required driving for the past 10 years. If more space is needed, please click the "ADD" button) Employer Name Date From Date To Address Phone Number Fax Number Job Title Supervisor Name Salary / Rate Reason for Leaving Work Performed While employed by this employer, were you subject to the Federal Motor Carrier Safety Regulations? Yes No Was this job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40? Yes No Add Remove PAST EMPLOYMENT VERIFICATION - TO BE READ AND SIGNED BY APPLICANT I hereby authorize all previous employers to release records of my employment, including assessment of my job performance, commercial driving, accidents, general work ability/fitness and drug & alcohol history to Sure Shot Drilling (SSD). I hereby release this company from any and all liability as a result of providing the requested information to Sure Shot Drilling. I also understand that I have the following rights regarding the investigative information that will be provided to Sure Shot Drilling: 1) the right to review information provided by previous employers; 2) the right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to SSD; 3) the right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and I cannot agree on the accuracy of the information. In order to review previous employer-provided investigative information, I must submit a written request to Sure Shot Drilling, which may be done at any time, including when applying or as late as 30 days after being employed or being notified of denial of employment. SSD will provide this information to me within five business days of receiving my written request. If SSD has not yet received the requested information from the previous employer(s), then the five-business day deadline will begin when SSD receives the requested safety performance history information. If I have not arranged to pick up or receive the requested records within thirty (30) days of SSD making them available, SSD may consider me to have waived my request to review the records. I also understand that misrepresentation or omission of information or facts may result in my rejection or dismissal. Date * TYPE FULL NAME IN THE BOX BELOW TO ACKNOWLEDGE * CERTIFICATE OF VIOLATIONS I certify that the following is a true and complete list of traffic violations (other than parking tickets) for which I have been convicted or forfeited bond or collateral, during the past 12 months. If you need more room, click the "ADD" button below. Date Offense Location Type of Vehicle Operated Add Remove If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation required to be listed according to Part 391.27 of the Federal Motor Carrier Safety Regulations during the past 12 months. Date * TYPE FULL NAME IN THE BOX BELOW TO ACKNOWLEDGE * FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT In accordance with the provisions of Section 604(b)(2)(A) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter I, of Public Law 104- 208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. These reports are required by Sections 382.413, 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations. Driver's License Number * State Issuing License * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming License Expiration Date * Date of Birth * Date * TYPE FULL NAME IN THE BOX BELOW TO ACKNOWLEDGE * DRIVER CERTIFICATION FOR OTHER COMPENSATED WORK INSTRUCTIONS: When employed by a motor carrier, a driver must report to the carrier all on-duty time including time working for other, employers. The definition of on-duty time found in Section 395.2 paragraphs (8) and (9) of the Federal Motor Carrier Safety Regulations includes time performing any other work in the capacity of, or in the employ or service of, a common, contract or private motor carrier, and performing any compensated work for any non-motor carrier entity. Are you currently working for another employer? * Yes No At this time do you intend to work for another employer while still employed by this company? Yes No I hereby certify that the information given above is true and I understand that once I become employed with this company, if I begin working for any additional employer(s) for compensation that I must inform this company immediately of such employment activity. Date * TYPE FULL NAME IN THE BOX BELOW TO ACKNOWLEDGE * FINAL ACKNOWLEDGMENT I acknowledge all information above is correct to the best of my knowledge. * I acknowledge Submit
