First Name: Initial: Last Name:

Street Address:

City: State: Zip:

Phone (Home): Phone (Cell):

Are you legally eligible 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 Well Servicing Manager Well Servicing Supervisor 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:

Does your present employer know of your plans to change:YesNo

May we contact the employers listed:YesNo

If not, please indicate which ones:

Please list any additional information that relates to your ability to perform the job for which you have applied, such as special training, machine operations, hobbies, languages, etc.:

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):