First Name: Initial: Last Name:

Street Address:

City: State: Zip:

Phone (Home): Phone (Cell):

If hired, would you be able to present evidence of U.S. citizenship or
proof of your legal right to work in the United States:YesNo

Are you 18 years or older:YesNo

Driver's License Number: Class: Endorsements:

Position applied for: Class A CDL Driver Class A CDL Driver with Winch Experience Class B CDL Driver Derrick Rig Operator Double Pole Rig Operator Equipment Operator Mechanic

Referred by:

Applied to this company before:YesNo

Which Energy Contractors Yard are you applying to work for? Clendenin, WV Jane Lew, WV Waynesburg, PA Weston, WV Williamsport, PA

Do you have any relatives that are currently Energy Contractors Employees?YesNo

If yes, who?

Would you prefer to work:Full TimePart TimeTemporary

Are you currently employed:YesNoSalary desired:

U.S. Armed Forces:YesNoRank and Branch:

Have you ever been convicted of a felony:YesNo

If so, please explain:

Emergency Contact

First Name: Last Name:

Street Address: City: Zip:

Phone (Primary): Phone (Secondary):