STOKER OILFIELD SERVICE EMPLOYMENT APPLICATION

Transcription

1 STOKER OILFIELD SERVICE EMPLOYMENT APPLICATION Applicant Full Name Home Phone Cell Phone Address Current Address: Number and street City State & Zip How were you referred to Company?: Employment Positions Position(s) applying for: Are you applying for: Temporary work such as summer or holiday work? [ ] Y or [ ] N Regular part-time work? [ ] Y or [ ] N Regular full-time work? [ ] Y or [ ] N What days and hours are you available for work? If applying for temporary work, when will you be available? If hired, on what date can you start working? / / Can you work on the weekends? [ ] Y or [ ] N Can you work evenings? [ ] Y or [ ] N Are you available to work overtime? [ ] Y or [ ] N Salary/ Wage per Hour desired: $

2 Personal Information: Have you ever applied to / worked for Company before? [ ] Y or [ ] N If yes, please explain (include date): Do you have any friends, relatives, or acquaintances working for Company? [ ] Y or [ ] N If yes, state name & relationship: Are you over the age of 18? (If under 18, hire is subject to verification of minimum legal age.) [ ] Y or [ ] N If hired, would you be able to present evidence of your U.S. citizenship or proof of your legal right to work in the United States? [ ] Y or [ ] N If hired, are you willing to submit to and pass a controlled substance test? [ ] Y or [ ] N Are you able to perform the essential functions of the job for which you are applying, either with / without reasonable accommodation? [ ] Y or [ ] N If no, describe the functions that cannot be performed (Note: Company complies with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. It is possible that a hire may be tested on skill/agility and may be subject to a medical examination conducted by a medical professional.) Have you ever been convicted of a criminal offense (felony or misdemeanor)? [ ] Y or [ ] N If yes, please describe the crime - state nature of the crime(s), when and where convicted and disposition of the case. (Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The date of the offense, the nature of the offense, including any significant details that affect the description of the

3 event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.) Education, Training and Experience High School: School name: School city, state, zip: Number of years completed: Did you graduate? [ ] Y or [ ] N Degree / diploma earned: College / University: School name: School city, state, zip: Number of years completed: Did you graduate? [ ] Y or [ ] N Degree / diploma earned: Vocational School: Name: City, state, zip: Number of years completed: Did you graduate? [ ] Y or [ ] N Degree / diploma? : Military: Branch: Rank in Military: Total Years of Service: Skills/duties: Related details: Additional Information Do you speak, write or understand any foreign languages? [ ] Y or [ ] N If yes, describe which languages(s) and how fluent of a speaker you consider yourself to be.

4 Do you have any other experience, training, qualifications, or skills which you feel should be brought to our attention, in the case that they make you especially suited for working with us? [ ] Y or [ ] N If yes, please explain Previous Employment Dates of Employment From To Company Position Held Supervisor Contact Number for Supervisor Position Held Responsibilities Dates of Employment From To Company Position Held Supervisor Contact Number for Supervisor Position Held

5 Responsibilities Dates of Employment From To Company Position Held Supervisor Contact Number for Supervisor Position Held Responsibilities References Give the names of three persons not related to you, whom you have known at least one year. NAME CONTACT NUMBER BUSINESS

6 AUTHORIZATION "I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from any liability for any damage that may result from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the forgoing, unless it is in writing and signed by an authorized company representative. The waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws." Signature Date

7 Consent to Investigate and Disclose Data I hereby allow Stoker Oilfield Service the right to contact and investigate my former and current employers to fully investigate my background. I also voluntarily consent to any lawful security examination and/or background checks. I authorize Stoker Oilfield Service to use any and all information acquired to make decisions regarding my employment. I understand and agree that if any adverse information is obtained or if any material facts are discovered which differ from those facts stated by me on my employment application, at my interview, or at any time prior to my commencing employment, I will not be offered the job. Furthermore, I understand and agree that if material facts are later discovered which are inconsistent with or differ from facts I furnished before taking the job, I will be disciplined, including immediate discharge without warning. Consent and Release Concerning Drug/Alcohol Testing Policy I acknowledge that I have received a copy of STOKER OILFIELD S Drug Testing Policy, that I have read and understand the policy, and that by signing this acknowledgment, I agree to adhere to the policy as a condition of my employment and/or continuing employment with STOKER OILFIELD. I also acknowledge that I am an at-will employee and that my employment may be terminated at any time for good cause, bad cause or no cause. I further acknowledge that my failure to adhere to this policy may subject me to disciplinary action, up to and including immediate termination without advance warning. I further acknowledge that I have reviewed the policy and have been given the opportunity to ask questions about the policy. I understand that my refusal to submit to a drug screen or a positive result on such a drug screen can lead to my immediate termination for work-related misconduct. Employee Signature Date

8 Acknowledgment, Consent and Release Form for STOKER OILFIELD No Handguns Policy I acknowledge that I have received, read and understand a copy of STOKER OILFIELD s No Handguns Policy. By signing this acknowledgment, I agree to adhere to the terms of the policy as a condition of my employment with STOKER OILFIELD. I also acknowledge that my employment is at will, meaning that it is of indefinite duration and may be terminated at any time, with or without advance notice, for good cause, bad cause or no cause at all. I further acknowledge that if I fail to adhere to this policy, I may be subject to disciplinary action up to and including immediate termination without prior warning. In connection with the enforcement of STOKER OILFIELD s No Handgun Policy, I give my consent to STOKER OILFIELD conducting reasonable searches for weapons prohibited by this policy. I understand that all vehicles owned or used by STOKER OILFIELD are subject to being searched at any time without my permission. I also acknowledge that I am prohibited from locking or otherwise securing any vehicle with any lock or locking device that is not supplied by STOKER OILFIELD. Acknowledgment of Receipt and Understanding of STOKER OILFIELD Policy Against Harassment in the Workplace I acknowledge that I have received a copy of STOKER OILFIELD Policy Against Harassment, that I have read and understand the policy, and that by signing this acknowledgment, I agree to adhere to the policy as a condition of my employment and/or continuing employment with STOKER OILFIELD. I acknowledge that I understand how to follow the procedures set out in this policy and that if I have any questions, I will ask for clarification. I agree to report any incident of harassment in a timely manner and I understand that there are a number of different individuals who are authorized to take my complaint and act on it appropriately. I further acknowledge that my failure to adhere to this policy may subject me to disciplinary action, up to and including immediate termination without advance warning. I have reviewed the Policy Against Harassment and have been given the opportunity to ask questions about the policy. I know that I may file a complaint of harassment or participate in an investigation without fear of retaliation. Employee Signature Date

9 Acknowledgement and Receipt of Employee Handbook Form RECORD OF RECEIPT OF EMPLOYEE HANDBOOK I acknowledge receiving the STOKER OILFIELD employee policy handbook. I CLEARLY UNDERSTAND THAT THIS POLICY HANDBOOK DOES NOT CREATE A CONTRACT FOR EMPLOYMENT WITH STOKER OILFIELD, AND THAT STOKER OILFIELD MAY CHANGE OR MODIFY THE POLICIES AND PROCEDURES IN THIS HANDBOOK AT ANY TIME, WITH OR WITHOUT PRIOR NOTICE. I HAVE READ AND UNDERSTOOD THE POLICIES OUTLINED IN THE STOKER OILFIELD HANDBOOK, AND AGREE TO BE BOUND BY THE COMPANY S RULES AND REGULATIONS DURING MY EMPLOYMENT WITH THE COMPANY. I UNDERSTAND THAT VIOLATING THE POLICIES AND RULES SET OUT IN THIS HANDBOOK MAY LEAD TO DISCIPLINE, UP TO AND INCLUDING TERMINATION. EMPLOYEE SIGNATURE DATE Revison 2 Page 25

10 Wage Deduction Agreement I understand and agree that my employer, STOKER OILFIELD may deduct money from my pay from time to time for reasons that fall into the following categories: 1. Any contributions I may make into a retirement or pension plan sponsored, controlled or managed by STOKER OILFIELD; 2. If I receive an overpayment of wages for any reason, repayment of such overpayments to STOKER OILFIELD; 3. The cost to STOKER OILFIELD of personal calls I may make on STOKER OILFIELD phones or on STOKER OILFIELD accounts; 4. The cost of repairing or replacing any STOKER OILFIELD supplies, materials, equipment, money or other property that I may damage (other than normal wear and tear), lose, fail to return or take without appropriate authorization from STOKER OILFIELD during my employment; 5. The cost of STOKER OILFIELD s uniforms if not returned; 6. If I am a salaried exempt employee who takes a full day of personal leave at my own request, the value of such leave may be deducted in eight hour increments. 7. If I take paid vacation or sick leave in advance of the date I would normally be entitled to it and I separate from STOKER OILFIELD before accruing time to cover such advance leave, the value of such leave taken in advance that is not so covered; I agree that STOKER OILFIELD may deduct money from my pay under the above circumstances, or if any of the other situations occur. Employee Signature Date

11 Motor Vehicle Report Notification & Authorization Form Date: (PLEASE PRINT OR TYPE ALL INFORMATION ON THIS FORM) Applicant/ Employee Name Applicant/Employee Address: City/State/Zip: Drivers License Number: State of Issue: Date of Birth: Social Security # I,, authorize Stoker Oilfield Service, Ltd to obtain driving records (motor vehicle reports) on my information shown above as part of the company s evaluation of my employment / insurance application. The reports may be obtained and produced by Sawyer & Associates Insurance Agency, LLC. These records will be obtained as part of the applicant or employee evaluation process, an assessment of my insurability or employability or for other permissible purposes. By signing this disclosure, I hereby authorize the company to procure such reports about me from time to time, as it deems appropriate, to evaluate my insurability or employability. Signature of Applicant / Employee

12 Employee Acknowledgment of Workers Compensation Network I have received information that tells me how to get health care under my employer s workers compensation insurance. If I am hurt on the job and live in a service area described in this information, I understand that: 1. I must choose a treating doctor from the list of doctors in the network. Or, I may ask my HMO primary care physician to agree to serve as my treating doctor. If I select my HMO primary care physician as my treating doctor, I will call Texas Mutual at (800) to notify them of my choice. 2. I must go to my treating doctor for all health care for my injury. If I need a specialist, my treating doctor will refer me. If I need emergency care, I may go anywhere. 3. The insurance carrier will pay the treating doctor and other network providers. 4. I might have to pay the bill if I get health care from someone other than a network doctor without network approval. 5. Making a false or fraudulent workers compensation claim is a crime that may result in fines and or imprisonment. Signature Date Printed Name I live at: Street Address City State Zip Code Name of Employer: STOKER OILFIELD SERVICE Name of Network: Texas Star Network Network service areas are subject to change. Call (800) if you need a network treating provider. Please indicate whether this is the: Initial Employee Notification Injury Notification (Date of Injury: / / ) DO NOT RETURN THIS FORM TO TEXAS MUTUAL INSURANCE COMPANY UNLESS REQUESTED Employee Notice of Network Requirements 2/08

13 PPE CERTIFICATION Employee Name Job Title I understand: When PPE is necessary during my work activities. What PPE I must wear (eye/face, hand, foot, head). I must inspect my PPE before and after each use. I must keep my PPE clean, sanitary, and in working order. I should never use defective PPE. I should notify my supervisor immediately of any defective PPE for replacement. Signed Date

14 Direct Deposit Authorization Form Company Name: Stoker Oilfield Service I (we) hereby authorize Stoker Oilfield Service to initiate debit entries to my (our) Checking/ Savings Account (select one) indicated below at the depository financial institution named below and to debit the same to such account. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law. Depository Name Branch City State Zip Routing Number Account Number This authorization is to remain in full force and effect until Stoker Oilfield Service has received written notification from me (or either of us) of its termination in such time and in such manner as to afford the company and the depository a reasonable opportunity to act on it. Print Name Signature Date

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