Employment Application - Horizontal Wireline

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Employment Application The information given on this form is for company use only. It will be to the applicant’s advantage to answer each question fully and accurately. The use of this

form does not indicate that there are any positions open and does not in any way obligate the company.

Full Name (First, Middle, Last):

Present Address (Street, City, State, Zip):

If your address has changed in the past three years, please provide all the addresses you have lived at for the past three years in the spaces provided:

Street, City, State, Zip: Dates at residence:



Home Phone Number: Cell Phone Number: Email:

Social Security Number: Date of Birth: Driver’s License Number: State: Expiration: Class/Endorsements: Are you a United States Citizen? YES NO

If NO, are you authorized by the U.S. Immigration Service to accept employment? YES NO Visa Number:

NOTE: Proof of citizenship or immigration status will be required upon employment.

Have you been convicted of a felony, or released from prison? YES NO If yes, please explain (attach a sheet if necessary):

NOTE: A yes answer does not automatically disqualify you from employment. The nature of the offense, date, and type of job you are applying for will be considered.

Referred by: Advertisement Walk in Employment Agency Friend/Relative-Name:

Have you applied for a job with Horizontal Wireline Services before? Yes No If Yes, When?

Have you ever worked for Horizontal Wireline Services before? Yes No If Yes, When?

Are you presently employed? Yes No if yes, may we contact your present employer? Yes No If NO, when did you leave your last employer?

What job are you applying? Type of Employment: Full Time Part Time Seasonal

If Seasonal, how long? On what date could you start work?

Are you willing to work shifts? YES NO Hours Available:

Days Available: Monday Tuesday Wednesday Thursday Friday Saturday Sunday Will you travel if the job requires it? YES NO

FMCSA REQUIREMENTS

Can you read and speak the English language, in accordance with Section 391.11(b)(2) or the FMCSR? Yes No Has any license, permit, or privilege been suspended or revoked? Yes No

Can you be incompliance with the FMCSR and comply with all Company policies? Yes No Have you ever been denied a license, permit, or privilege to operate a motor vehicle? Yes No

Have you ever been convicted for possession, sale, or use of a narcotic drug, amphetamine or other controlled substance? Yes No Have you ever been convicted of a felony? Yes No

Alcohol test with a result of 0.02 or greater? Yes No Verified “positive” on controlled substance test results? Yes No Failed drug or alcohol tests at any previous employers? Yes No Refusal to be tested? Yes No

Have you ever tested positive or refused to test for any pre-employment drug/alcohol test administered by an employer to which you applied for, but did not obtain employment during the past two years? Yes No If you answered YES to any of the questions above, please state, the circumstances and date (attached a sheet if necessary):



Sec. 40.25(j) As the employer, you must also ask the employee whether he or she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee

applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years. If the employee admits that he or she had a positive test or a refusal to

test, you must not use the employee to perform safety-sensitive functions for you, until and unless the employee documents successful completion of the return-to-duty process. (See Sec. 40.25(b)(5) and (e))

The prospective employee is required by Sec. 40.25(j) to respond to the following questions:

1) Have you tested positive, or refused to test on any pre-employment drug or alcohol test administered by an employer to which you have applied, but did not obtain safety-sensitive transportation work covered

by DOT agency and alcohol testing rules during the past two years? Yes No

2) If you answered yes, can you provide/obtain proof that you’ve successfully completed the DOT return-to-work duty requirements? Yes No

Section 391.27 Driver Requirements: Each driver shall furnish the carrier at least once every 12 months a list of violations of motor vehicle traffic laws and ordinances (other than violations involving only parking) of which

the driver has been convicted, or in account of which he/she has forfeited bond or collateral during the preceding 12 months

As required by part 382.413 of the Federal Motor Carrier Safety Regulations, are you aware of any:

Date of Violation/Conviction Offense Location (City/State) Type of Vehicle Operated

I certify if no violations listed above, that I have not been convicted of forfeited bond or

collateral on account of any violation required to be listed in the past 12 months. Applicant Signature Date

Driving Experience: Class of Equipment Type of Equipment Dates of Experience Approx Miles Travel

Straight Truck

Tractor/Semi Trailer

Tractor/Two Trailers

Other

Education: If not a high school graduate, insert number of school years completed. If no degree has been obtained, insert college credit hours completed.

Name Location Dates Attended Major Course Degree Grade Average

High School

College

Graduate School

Special or Technical Training

Activities: You may exclude activities which would reveal your age, sex, race, religion, national origin, ancestry, disability, or other protected status.

Special Skills: Summarize special job-related skills and qualifications acquired from employment or other experience.



Employment History: Note: Starting with present or most recent employer, account for periods of employment for the last ten years including all full and part-time employment, self-employment, military services, and any period of

unemployment. You may use an extra sheet if more space is necessary. Phone Numbers must be included.

Employer Name: Telephone:

Address (City, State): Fax:

Position: Immediate Supervisor:

Start Date: End Date:

Start Rate: End Rate:

Reason for leaving:

Describe Work Performed: (Work can be described through your resume)






Reason for leaving:







Reason for leaving:


Attached an additional sheet if necessary



Employment Agreement:

I understand that if employment is offered it is not for any definite period of time and is subject to termination with or without cause by the company or at my own election at any

time. I further understand that my employment would be at-will, and that no statements have been made indicating otherwise, and that this policy cannot be change except in a

written document signed by an authorized officer of the company. If accepted, I must conform also to all company rules and regulations as made known at the time of

employment or any other time thereafter; to perform all duties assigned to me to the best of my ability; and to be responsible to the company for any loss or damage of any tools,

keys, equipment, or any other property entrusted to my care. The compensation paid to employees for services covers inventions and improvements pertaining to the business of

the company and that, as a further condition of employment in certain classes of work, it will be necessary to sign an agreement relating to the assignment of inventions to the

company.

I certify that the facts contained in this application are true and completed to the best of my knowledge and understanding that, if employed, falsified statements on this

application shall be sufficient reason for discharge from the service of the company.

Applicant Signature: Date:



ATF AND LICENSE QUALIFICATION

This form is to verify that the signed candidate below complies with the necessary laws and regulations as pertains to explosive material usage and requirement per the Safe Explosives Act of 2002, Organized Crime Control Act of 1970, and BATFE Title 26, Code of Federal Regulations Part 555 – Commerce in Explosives.

I certify the following statements are true and correct: Print Name

1. I am 21 years of age or older.

2. I have never been convicted of a felony.

3. I have never been convicted of a crime that is punishable by more than one year of imprisonment.

4. I am not under indictment for a crime punishable by more than one year of imprisonment.

5. I am not currently under deferred adjudication for a crime punishable by more than one year of imprisonment.

6. I am not a fugitive from justice.

7. I have not been adjudicated to have a mental defect and have never been committed to a mental institution.

8. I am not an unlawful user of or addicted to any controlled substance (as defined in section 102 of the Controlled Substances Act –

including but not limited to marijuana, depressants, stimulants, and narcotic drugs)

9. I have not been dishonorably discharged from the armed forces of the United States.

10. I am a United States Citizen.

11. I have not renounced my United States Citizenship.

555.162 False statement or representation. Any person who knowingly withholds information or makes any false or fictitious oral or written statement or furnishes or exhibits any false, fictitious, or misrepresented identification, intended or likely to deceive for the purpose of obtaining explosive materials, or license, permit, exemption, or relief from disability under the Act, shall be fined not more than $10,000 or imprisoned not more than 10 years, or both. I certify that the information I have given above is true and complete. I understand that any false, incorrect or misleading information, or the omission of any pertinent information, may be sufficient reason for my discharge, in hired. Furthermore, I have read and understand BATFE 2007 code 27 Section I part 555.162 provided above. Signature Date



CONTROLLED SUBSTANCE POLICY

To the Applicant: As part of Horizontal Wireline Services program to provide a safe and healthy work environment for its employees, HORIZONTAL Wireline Services requires pre-employment drug tests. If the test is confirmed as positive, the results will be considered in any employment decision and may result in a rejection of an application for employment. It is important that you disclose the usage of any drugs, whether they are prescribed by a physician or otherwise. Horizontal Wireline Services needs to be made aware of any prescribed medications taken under the direction of a physician that could interfere with your performance on the job. You should also understand that Horizontal Wireline Services reserves the right to periodically test for drug usage and reserves the right on Horizontal Wireline Services premises to search any areas, including lockers, lunch boxes, brief cases, and other areas as part of this program. I have read the foregoing statement and understand the employment screening process includes a urine test which may disclose usage of drugs or alcohol, or which may reveal substance abuse or chemical dependency. I hereby consent to such tests and to the disclosure of the results of the tests to Horizontal Wireline Services for its use and internal communication. I release and discharge Horizontal Wireline Services and any laboratory which performs analysis from any claim or liability arising out of such test including, without limitation, the testing procedures, the analysis or the disclosure of its results. Signature Date

NAME/coMpANy NAME/coMpANy

ADDRESS ADDRESS (P.O. Box not acceptable), need to provide physical location of business/residence

cITy STATE ZIp coDE cITy STATE ZIp coDE

DAyTIME TELEpHoNE NuMbER (required) DAyTIME TELEpHoNE NuMbER (required)

RELATIoNSHIp To DRIvER (required) ________________________________________________ RELATIoNSHIp To DRIvER (required) ________________________________________

Intended use of the Information Requested: CHECK ONLY ONE

❏ B = Driver Release (Driver must complete Section E.) ❏ C = Credit Business (Legitimate Business need in connection with a business

transaction initiated by the driver.) ❏ C = Credit Potential Investor, Server or Current Insurer (In connection

with an assessment of the credit/payment risks associated with an existing credit obligation.)

❏ E = Employment (To support the hiring or the continuation of employment. Driver must complete Section E.)

❏ R = Insurance Company requesting record of person it intends to insure, now insures, or has rejected for insurance.

❏ K = Court Order must be attached. (A subpoena issued in compliance with Pa. R.C.P. 4009.21 will be accepted in lieu of a court order).

❏ L = Attorney representing driver identified in Section c (Driver must complete Section E.)

cHEcK (✔) oNE oNLy: ❑ FuLL HISToRy: $5.00 FEE❑ bASIc INFoRMATIoN: $5.00 FEE (Driver history is not included) ❑ cERTIFIED DRIvER REcoRD: $10.00 FEE❑ 3 yEAR DRIvER REcoRD: $5.00 FEE ❑ copy oF DocuMENT FRoM FILE (MIcRoFILM): $5.00 FEE❑ 10 yEAR DRIvER REcoRD: $5.00 FEE (Employment Purposes Only) ❑ cERTIFIED copy oF DocuMENT FRoM FILE: $10.00 FEE

You may obtain a copy of your own 3 year, 10 year and/or Full History Driving Record on PennDOT'S website at www.dmv.state.pa.us REQUESTER INFORMATION B END USER OF INFORMATION BEINg REQUESTED

X

A

NOTARIZATION NOT REQUIRED WHEN REQUESTING YOUR OWN RECORD

AFFIDAVIT OF INTENDED USED

MoNTH DAy yEAR

DRIVER INFORMATIONNAME: LAST FIRST INITIAL

ADDRESS

cITy

STATE ZIp coDE

pHoNE NuMbER

DRIvER NuMbERDATE oF bIRTH

C

MESSENgER NO.

signature

SIGNATuRE oF REQuESTER

pRINTED NAME oF REQuESTER

E DRIVER RELEASE

I _______________________________________ hereby request

the Department of Transportation to furnish a copy of my pA Driver's Record to ____________________________________________

NAME oF DRIvER

NAME oF pERSoN/coMpANy

SIGNATuRE oF DRIvER DATE X

TypE oF DocuMENT DATE oF vIoLATIoN

(see list of available documents below)

Documents Available: •Citations •SuspensionCreditAffidavits •CourtCertifications •Suspension/RevocationLetters •Applications •RestorationLetters •LicenseRenewals •RescindLetters •Judgments •DepartmentHearingorExamNotice

F MICROFILM X

SubScRIbED AND SWoRN

To bEFoRE ME: MoNTH DAy yEAR

NO

TAR

IZAT

ION

SIGNATuRE oF pERSoN ADMINISTERING oATH

SEAL

X

SIgN IN PRESENCE OF NOTARY

REQUEST FOR DRIVER INFORMATIONThe most current version of this form can be found at www.dmv.state.pa.us

PLEASE TYPE OR PRINT IN BLUE OR BLACK INKDO NOT SEND CASH • See reverSe for inStruCtionS

DL-503 (7-11)

DEPARTMENT OF TRANSPORTATION

Bureau of Driver LicensingP.O. Box 68695Harrisburg, PA 17106-8695

I hereby certify that _______________________________________________

willusethedriverrecordabstract(s)requiredpursuanttoSection6114ofthePennsylvaniaVehicleCode,forthepurposecheckedaboveonlyandnootherreason.Thisaffidavit isfiledincompliancewithSection607of theFairCreditReportingAct. I/Wehavereadandsigned thisformafteritscompletion,andI/Weswearoraffirmthatthestatementsmade herein are true and correct, and that any statement made on or pursuanttothisformissubjecttothepenaltiesof18PaC.S.Section4903(a)(2)(relatingtofalseswearing),whichshallincludepunishmentofafinenotexceeding$5,000,ortoatermofimprisonmentofnotmorethan two years, or both.

_______________________________________________________________

Title ___________________________________________________________

________________________________________________ ________________________________________________

www.DISA.com

This document contains sensitive information. Keep this document separate from personnel records. Page 1

EMPLOYEE SCREENING RELEASE

APPLICANT/EMPLOYEE COMPLETE THE FOLLOWING

1. In connection with my application for employment, I understand that a consumer report or an investigative

consumer report may be requested from DISA Inc. that may include information as to my character, general

reputation, personal characteristics, mode of living and credit standing.

a. I understand that as directed by company policy and consistent with the job described, that information

such as but not limit to criminal and warrant records, social security number verification, credit and

financial information, education, driving history, employment history, personal references,

certifications and professional licenses, drug testing results, address history, and workers compensation

records may be obtained.

b. I understand that such information may be obtained by direct or indirect contact from former

employers, schools, courts, public agencies, or any other agency or institution and through personal

interviews with neighbors, friends, associates, acquaintances, or other persons who have such

knowledge.

2. Medical and workers’ compensation information will only be requested in compliance with the Federal

Americans with Disabilities Act (ADA) and/or any other applicable state laws. According to the Fair Credit

Reporting Act, I am entitled to know if employment is denied because of information obtained by my

prospective employer from a consumer reporting agency. If so, I will be notified and given the name and

address of the agency or the source which provided the information.

3. I acknowledge that a telephonic facsimile (FAX) or photographic copy shall be as valid as the original. This

release is valid for most federal, state and county agencies.

4. Additional State Law Notices:

a. California Applicants/Employees Only: I have the right to request a copy of my consumer report from

DISA, Inc. by checking this box . The report will be sent directly to me by DISA, Inc. to my most

current address listed. I understand that I have the right to inspect visually the files concerning me

maintained by an investigative consumer reporting agency during normal business hours upon

reasonable notice. The inspection can be done in person if I appear in person and furnish proper

identification. I am entitled to a copy of the file for a fee not to exceed the actual cost of duplication. I

am entitled to be accompanied by one person of my choosing, who shall furnish reasonable

identification. The inspection can also be done via certified mail if I make a written request, with

proper identification, for copies to be sent to a specified address. I can also request a summary of the

information to be provided by telephone if I make a written request, with proper identification for

telephone disclosure. I further understand that the investigative consumer reporting agency shall

provide trained personnel to explain to me any of the information furnished to me. I will receive from

the investigative consumer reporting agency a written explanation of any coded information contained

in files maintained on me. The nature and scope of the investigation is as follows:

______________________________________________________________________________

b. Massachusetts Applicants/Employees Only: The nature and scope of the investigation is as follows:

______________________________________________________________________________. I

have a right to obtain a copy of this report. I understand that in the event that I am denied employment

based in whole, or in part, on the information obtained in the DISA, Inc. report, I will be provided a

copy of the report and a description in writing of my applicable state rights.

c. Maine Applicants/Employees Only: I have the right, upon request, to be informed of whether an

investigative consumer report was requested. If requested my report will be obtained from DISA, Inc,

12600 Northborough Drive, Suite 300, Houston, TX 77067, 1-800-752-6432. This is the nearest unit

designated to handle inquires for DISA, Inc on any reports issued concerning me. I have the right,

under Maine law, to request and promptly receive from DISA, Inc. copies of my consumer report(s).

d. Minnesota Applicants/Employees Only: I have the right to request a copy of my consumer report from


www.DISA.com

This document contains sensitive information. Keep this document separate from personnel records. Page 2

EMPLOYEE SCREENING RELEASE

current address listed. I also have the right upon my direct request to DISA, Inc. to obtain a complete

and accurate disclosure of the nature and scope of the consumer report. The disclosure obtained from

DISA, Inc. will be in writing and mailed or delivered within 5 days after the request for the disclosure

was received or the consumer report was requested, whichever is later.

e. New Jersey Applicants/Employees Only: The specific nature and scope of the investigation involving

personal interviews includes: ________________________________________________________.

f. New York Applicants/Employees Only: I have the right, upon written request, to be informed of

whether or not a consumer report was requested. If requested my report will be obtained from DISA,

Inc, 12600 Northborough Drive, Suite 300, Houston, TX 77067, 1-800-752-6432. I may inspect and

receive a copy of my report by contacting DISA, Inc.

g. Oklahoma Applicants/Employees Only: I have the right to request a copy of my consumer report from


current address listed.

h. Washington Applicants/Employees Only: I understand before I am denied employment based in

whole, or in part, on the information obtained in the DISA, Inc. report, I will be provided a copy of the

report and a description in writing of my applicable state rights.

The following information is required by law enforcement agencies and other entities for positive identification

purposes when checking public records. It is confidential and will not be used for any other purposes.

Please Print Your Full Name as it Appears on Your License:

Last First Middle

Please Print Other Names You Have Used: _________________________________________________________

Home Address: ________________________________________________________________________________

_____________________________________________________________________________________________

Social Security Number: Date of Birth:

Drivers License Number: State Issuing License:

By signing this form I hereby authorize, without reservation, any law enforcement agency, institution, information

service bureau, school, employer, reference, insurance company, or any other source contacted by DISA, Inc. or its

agent, to furnish the information described in Section 1. I hereby release the employer and agents and all persons,

agencies, and entities providing information or reports about me from any and all liability arising out of the requests

for or release of any of the above mentioned information or reports. I acknowledge that I have read and understood

the Employee Screening Release Authorization form. I understand that if hired my consent will apply throughout the

term of my employment.

Signature: Today’s Date:

TCD

Typewritten Text

D E L M E R T A M A R A C

Employment Application - Horizontal Wireline

Documents

Transcript of Employment Application - Horizontal Wireline