Job Application Form

Date:

Name:

Address:

City:

State:

Zip:

Phone:

Email:

Position Sought: Full Time: Part Time:

Date Available:

Salary Desired:

SSN:

Are you legally eligible for employment in the Untied States for an indefinite term? Yes: No:

Are you over the age of 18? Yes: No:

Preferences for work location? Select a State CO ND PA WY

Please indicate education or training which you believe qualifies you for the position you are seeking.

High School: (Number of Years Completed) Select a Number 1 2 3 4 Diploma:Yes: No: GED:Yes: No:

School(s):

City/State:

College and/or Vocational School: (Number of Years Completed) Select a Number 1 2 3 4

School(s):

City/State:

Major(s):

Degree(s) and/or Certificates Earned:

Professional License or Membership:

Summarize special job-related skills and qualifications from employment or other experience, including software, office skills, other languages and proficiency.

Have you ever submitted an application with this Company? Yes: No:

If yes, please give date:

Have you ever been employed with any facility of this Company? Yes: No:

If yes, please state facility name, location, and dates of employment:

Facility Name:

Facility Location:

Dates of Employment:

Do you have any relatives employed with Western Pump & Dredge? Yes: No:

If yes, please give name, relationship and job title:

Relative Name:

Relationship:

Job Title:

All applicants must provide the following information on their last three employers as a minimum. List complete mailing addresses including street or P.O. Box, City, State, and Zip. Additionally you must provide a contact person. List last employer first including U.S. Military Service.

May we contact your present employer: Yes: No:

If employment was under a different name, indicate name:

Employer:

Address:

Phone:

Position:

Dates of Employment:

Salary:

Supervisor:

Duties:

Number of Hours: Full Time: Part Time:

Reason for leaving:

Were you subject to Federal Motor Carrier Safety Administration Rules* while employed?
Yes: No:

Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49CFR Parts 40 and 382?
Yes: No:

If employment was under a different name, indicate name:

Employer:

Address:

Phone:

Position:

Dates of Employment:

Salary:

Supervisor:

Duties:

Number of Hours: Full Time: Part Time:

Reason for leaving:

Were you subject to Federal Motor Carrier Safety Administration Rules* while employed?
Yes: No:

Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49CFR Parts 40 and 382?
Yes: No:

If employment was under a different name, indicate name:

Employer:

Address:

Phone:

Position:

Dates of Employment:

Salary:

Supervisor:

Duties:

Number of Hours: Full Time: Part Time:

Reason for leaving:

Were you subject to Federal Motor Carrier Safety Administration Rules* while employed?
Yes: No:

Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49CFR Parts 40 and 382?
Yes: No:

List all motor vehicle accidents for the last three years. If you have no accidents in the previous three years, write "None".

Last Accident:

Date:

Nature of Accident: Roll over, rear end, etc.

Fatalities:

Injuries:

Hazardous Materials Spill:

Next Previous:

Date:

Nature of Accident: Roll over, rear end, etc.

Fatalities:

Injuries:

Hazardous Materials Spill:

Next Previous:

Date:

Nature of Accident: Roll over, rear end, etc.

Fatalities:

Injuries:

Hazardous Materials Spill:

List incidents for the past five years (other than parking violations). If you have had no convictions, write "None".

List all drivers licenses or permits held during the last three years.

License Type:

State:

License No:

Expiration:

License Type:

State:

License No:

Expiration:

License Type:

State:

License No:

Expiration:

Do you currently have a valid driver's license?    Yes: No:

Do you currently have a valid driver's license permit or privilege to operate a motor vehicle?    Yes: No:

Have you ever been denied a license?    Yes: No:

Has any license, permit or privilege ever been revoked?    Yes: No:

If the answer to either of the last 2 questions
directly above is yes, give details.

Check yes or no and indicate the amount of experience in each type.

Straight Truck Yes: No: Select Type Van Tank Flatbed Dump Reefer Dates: Miles:

Straight Truck Yes: No: Select Type Van Tank Flatbed Dump Reefer Dates: Miles:

Tractor Trailer Yes: No: Select Type Van Tank Flatbed Dump Reefer Dates: Miles:

Tractor & 2 Trailers Yes: No: Select Type Van Tank Flatbed Dump Reefer Dates: Miles:

Motor Coach/Bus Yes: No: Select Type Van Tank Flatbed Dump Reefer Dates: Miles:

Other Yes: No: Select Type Van Tank Flatbed Dump Reefer Dates: Miles:

List states operated in during the last 5 years:

Did an employee of the Company refer you to complete this employment application?     Yes: No:   

If yes, who?

List three personal references of people we may contact who are not related to you.

Name:

Address:

Phone:

Name:

Address:

Phone:

Name:

Address:

Phone:

Please list all convictions. All convictions in federal and state courts are criminal convictions and must be disclosed. Disclosure of such convictions are required even if you did not spend any time in jail and/or were not required to pay a fine. You may omit any charges that were dismissed or resulted in acquittal, any offense that was finally adjudicated in the juvenile court or juvenile delinquency proceedings, or any conviction or deferred adjudication that has been set aside vacated, annulled, expunged or sealed. Disclosure of your background will not automatically preclude you from employment.

Yes, I have a conviction(s) in federal and/or state court as described above which is fully disclosed below.



No, I do not have a conviction(s) in federal and/or state court as described.

I agree to the following terms and conditions: 1) employment may be terminated at will at any time, with or without cause, at either the employee's option or the option of Western Pump and Dredge; 2) the filing of this application in no way obligates this Company to employ me and the Company reserves the right to reject any applicant for employment 3) any misstatement or omission of fact on this application including the failure to disclose convictions as described above, is considered cause for disqualification, or if employed, termination.

The company shall have the right to obtain from the above named former employers any information which they have concerning me and hereby request said references and former employers to make any such information available to the Company and agree to hold said parties harmless for doing so. I understand the information I provided may be used and those employers will be contacted for the purpose of investigating my safety performance history required by 49 CFR 391.3 (d) and (e). I understand I have a right to:

1. Review information provided by former employers.
2. Have errors in the information corrected by previous employers and have those employers resend the corrected information to Western Pump and Dredge.
3. Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.