O KEEFE DRILLING EMPLOLYMENT APPLICATION

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1 O KEEFE DRILLING EMPLOLYMENT APPLICATION P.O. BOX 3810 BUTTE, MT APPLICANT INFORMATION Last Name First M.I. Date Street Apartment/Unit # City State ZIP Phone Date Available Position Applied for Social Security No. Desired Salary Are you a citizen of the United States? YES NO If no, are you authorized to work in the U.S.? YES NO Have you ever worked for this company? YES NO If so, when? Have you ever been convicted of a felony? YES NO If yes, explain SPECIAL SKILLS AND TRAINING Drilling: Heavy Equipment: Welding: Other: EDUCATION High School Did you graduate? YES NO Degree College Did you graduate? YES NO Degree Other REFERENCES Please list three professional references. Full Name Did you graduate? YES NO Degree Relationship Full Name Relationship Full Name Relationship

2 PREVIOUS EMPLOYMENT O KEEFE DRILLING EMPLOLYMENT APPLICATION Supervisor Job Title Starting Salary $ Ending Salary $ Responsibilities Reason for Leaving May we contact your previous supervisor for a reference? YES NO Supervisor Job Title Starting Salary $ Ending Salary $ Responsibilities Reason for Leaving May we contact your previous supervisor for a reference? YES NO Supervisor Job Title Starting Salary $ Ending Salary $ Responsibilities Reason for Leaving May we contact your previous supervisor for a reference? YES NO MILITARY SERVICE Branch Rank at Discharge Type of Discharge If other than honorable, explain DISCLAIMER AND SIGNATURE I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. Signature Date

3 Driver Experience & Qualification O KEEFE DRILLING EMPLOLYMENT APPLICATION Licenses State License Number Type Expiration Date Drivers Licenses Held in Past 3 yrs. Please provide Years. Question YES NO Have you ever been denied a license permit or privilege to operate a motor Vehicle? Has any license permit or privilege ever been suspended or revoked? Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations? ** If you answered YES to any of the above questions attach a statement giving details. Driving Experience Class of Equipment Straight Truck Tractor & Semi-Trailer Twin Trailers Other Type of Equipment (Van, Tank, Flat, Etc.) Dates Apx. Miles List States operated in during last five years. List special courses or training that will help you as a driver. List Safe Driving awards held and who awards were presented by? Accident Review past 3 years. (Attach separate sheet if more space is needed) Dates Nature of Accident Fatalities Injuries Last Accident Next Previous Next Previous Traffic convictions and forfeitures for the past 3 years. (No parking violations) Location Date Charge Penalty

4 O KEEFE DRILLING EMPLOLYMENT APPLICATION Per the job description attached, the job may require lifting up to 50 pounds. Do you have any physical limitations or prior injuries to the back, knee, thighs or shoulders that would limit your ability to perform the job description? NO YES If YES, please Explain: This job may require a great deal of hand dexterity, do you have any prior injuries or limitations with regard to the arms, hands, wrist, or fingers which could interfere with completion of the job duties? NO YES If YES, please Explain: your knowledge, do you have any other limitations or prior injuries which could interfere with completion of job duties? NO YES If YES, please Explain: Acknowledgment I have read and acknowledge the receipt of the attached O Keefe Drilling Company job description and Controlled Substance Policy from the Safety Manual. I agree to submit to a urinalysis screening test at the time of the pre-employment and D.O.T physical exam. I understand that if I refuse this test I will not be considered for employment. I understand full-time employees newly hired are subjected to a 6 month evaluation or introductory period to verify skills, capabilities and suitability for our company. The 6 month evaluation period does not include lay off time and begins when actually beginning to work for O Keefe Drilling. At the end of the 6 months, the supervisor may extend the period for additional time at his or her discretion. Signature Date

5 Title: Sampler/ Third Hand O KEEFE DRILLING EMPLOLYMENT APPLICATION Purpose: collect the drill hole samples and record them per the mining company s instructions. assist the driller and driller helper. Responsibilities: -Know the mining company requirements for sampling. -Have adequate supplies on hand to contain the sample. -Record, tag and log the sample correctly. -Adequately split samples to specifications for each sample bag. Each bag is 30inches by 16 inches and can weigh up to 25 pounds. -Maintain and clean sampling devise on a regular basis. -Assist the driller and driller helper in whatever way they deem necessary to effectively complete the job at hand. -Addition jobs that may be required but not limited to: maintenance of the drill rig or auxiliary trucks, movement of equipment to the next location, packing up and cleaning of the job site, loading of materials or tools used, assisting the process of lay8ing down drill rods, and making connections coming out of the hole. Education and Training: -Minimum of High School diploma or equivalent. -MSHA training and updating. -General understanding of mechanics and engine maintenance. -OSHA 40hr Hazwoper helpful but not necessary Requirements: -Must be able to understand written mining company requirements for sampling and keep adequate records. -Additional lifting, ability to lift 50 pounds. -Physical good health is the employees responsibility; however, the company will provide and require a regular physical that may include drug screening, blood tests, back x-rays and other test required by the client on a specific job site. Recommended: -Commercial Driver s License with appropriate endorsements for the vehicles included in the drilling assignment or projects. A Commercial Driver s License is necessary for advancement.

6 Prepared: April 2011

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