Applicant s Name: Non-Driver Application for Employment: (Last Name) (First Name) (Middle Initial) (Date of Application) Current Address: (Current Street Address) (City) (State) (Zip Code) *If at the above address less than three (3) years, list below all residences for the past three years. Attach a separate sheet if necessary. Previous Addresses: Home Phone: ( ) Cell Phone: ( ) Email Address: Fax Number: ( ) Date of Birth: Social Security Number: Desired Position: Position Applying For: State: (Warehouse or Non-CDL Mobile Fueler) (City & State of Operation) What shifts are you able to work: Salary Desired: Driver s License Information: Driver s License Number: Issuing State: License Class (A/B): Endorsements: CDL Issue Date: CDL Expiration Date: Do you have any If yes, restrictions on your license? please explain: Has your license, or permit to drive or privilege to operate a motor vehicle ever been denied, revoked, or suspended? If yes, please provide a statement detailing the facts and circumstances:
Personal Information: Are you a citizen of the United States? If hired, can you provide proof? Have you ever been convicted of a felony? If yes, please explain: Did you graduate High School? If no, do you have a GED? Did you graduate Truck Driving School? If yes, name of Truck Driving School? Have you ever served in the U.S. Military Service? From/To? What branch of service? (Army, Navy, Marine, etc ) Final Rank? Have you ever worked for Chemoil before? If yes, when? Were you referred to Chemoil by a Chemoil Employee? If yes, employee name? Motor Vehicle Record Release: I hereby authorize you to release my Motor Vehicle Record (MVR) to Chemoil Energy pursuant to the Federal Motor Carrier Safety Regulations, parts 391.23 (a)(1) and 391.25 (a)(b)(1) and (2). You are released from any and all liability which may result from furnishing such information. I further understand this information will be used for permissible purposes and will not be disclosed or transferred to other parties not affiliated with Chemoil Energy. This is a consumer report and the information obtained will not be used in violation of any federal, state, or equal opportunity law or regulation. Upon receipt and review of the report; and before taking any adverse action based in whole or in part of the report; Chemoil Energy will provide the applicant a copy of the report and the summary of consumer rights as provided with the report by the consumer reporting agency. Applicant Signature: X Date: X 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. I further understand that any misleading, incorrect, or omitted statements or information can render this application void and if employed would be just cause for termination. Applicant Signature: X Date: X
Work History: (List current or most recent employer first, then all previous employers for the last 10 years. Account for all periods of unemployment or self-employment. (Your application will not be processed without 10 years work history.) Current or Last Employer Name: Job Title: Supervisor Name: Dates of Service From: To: Wages: Phone Number: ( ) Contact Name: Job Title: Supervisor Name: Dates of Service From: To: Wages: Phone Number: ( ) Contact Name:
Job Title: Supervisor Name: Dates of Service From: To: Wages: Phone Number: ( ) Contact Name: Job Title: Supervisor Name: Dates of Service From: To: Wages: Phone Number: ( ) Contact Name: