COOPER NATURAL RESOURCES, INC.
    APPLICATION FOR EMPLOYMENT

    Application Information

    All Fields In This Section Are Required.

    Are you a citizen of the United States? YESNO

    If no, are you authorized to work in the U.S.? YESNO

    Have you ever worked for this company? YESNO

    If yes, when?

    Have you ever been convicted of a felony? YESNO

    If yes, explain:

    Are you currently employed? YESNO

    If not, how long unemployed?

    Is there any reason you might not be able to perform the function or the job for which you are applying? YESNO

    If yes, explain:

    Employment History

    All driver applicants must provide the following information on all employers during the preceding 10 years. List complete mailing address, street number, phone numbers, fax number, City, State, and Zip Codes.

    Applicants to drive a commercial motor vehicle in intrastate or interstate commerce shall provide information on those employers for whom the applicant operated such vehicle.

    Were you subject to drug testing while employed? YESNO


    Are you related in any way to a current CNR employee? YESNO

    If yes, to whom and what is the relation?  

    Cooper Natural Resources, Inc.

    TO BE READ AND SIGNED BY THE APPLICANT

    I authorize you to make such investigations and inquiries of my personal background, employment history, medical history, driving record, academic/professional credentials, military service, and other related matters as may be necessary in arriving at an employment decision and as necessary throughout the course of my employment. (Generally, inquiries regarding medical history will be made only after a conditional offer of employment has been extended.) I hereby release former employers, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application for employment. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in immediate discharge.

    I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my dates of employment, work performance, reason for separation and wage information as needed. I understand I have the right to:

    • Review information provided by previous employers;
    • Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and
    • 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.

    I am aware any offer of employment will be contingent upon satisfactory completion of a pre-employment drug screen and physical evaluation. The offer of employment will be withdrawn if the result of either is unsatisfactory.

    If you wish to review previous employer-provided investigative information, you must submit a written request to the Company, no later than 30 days after being employed or being notified of denial of employment. The Company will provide the requested investigative information to you within five (5) business days of receiving this written request, or five (5) business days of receipt of the requested information from the previous employer, whichever is later.

    This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge.

    Date:
    Applicant Signature:


    FOR COMPANY USE


    APPLICANT HIRED ______________________ REJECTED ______________________
    DATE EMPLPOYED ______________________ DATE OF TERMINATION ______________________

    DEPARTMENT ______________________ CLASSIFICATION ______________________