ENERGY SERVICES GROUP, INC.
APPLICATION FOR EMPLOYMENT
All Fields Required. Use "N/A" For Fields That Don't Apply
List all States in which you have held a driver's license in the last 3 years
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.
(Note: List employers in reverse order starting with the most recent. Add another sheet as necessary.)
Add Additional Employer? YES
Accident Record for the Past 3 Years
(If there are no accidents to report, indicate with "N/A" or "None")
Straight Truck, Tractor & Tanker, Tractor/Trailer Combo, Other
List All Traffic Fines and Forfeitures for the Past 3 Years
(If there is nothing to report, indicate with “N/A” or “None”)
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? YESNO
B. Has any license you held ever been suspended or revoked? YESNO
If you answered yes to any of the above, give details below.
C. Have you ever tested positive, or refused to test, on any pre-employment drug test administered by an employer to which you applied for, but did not obtain, safety sensitive transportation work covered by DOT agency drug testing rules during the past two years? YESNO
D. If you answered yes, can you provide or obtain proof that you’ve successfully completed the DOT return-to-duty requirements? YESNO
E. Have you ever been convicted of a felony? YESNO
If you answered “yes” to A, B, or E above, provide a detailed explanation below:
Cooper Natural Resources, Inc.
Energy Services Group, 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.
FOR COMPANY USE
APPLICANT HIRED ______________________ REJECTED ______________________
DATE EMPLPOYED ______________________ DATE OF TERMINATION ______________________
DEPARTMENT ______________________ CLASSIFICATION ______________________
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service
1. In connection with your application for employment with Cooper natural Resources (“Prospective Employer’), Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).
When the application for employment is submitted in person, if the Perspective Employer uses any information it obtains form FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report.
When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business day of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act.
The Prospective Employer cannot obtain background reports from the FMCSA unless you consent in writing.
If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below.
2. I authorize Cooper Natural Resources (“Prospective Employer”) to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am consenting to the release of safety performance information including crash data for the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee.
3. I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I am challenging crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.
4. Please note: Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections with or without violations, appear on the PSP report. State citations associated with FMCSA violations that have been adjudicated by a court of law will also appear, and remain on a PSP report.
I have read the above Notice Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this consent form, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents and/or affiliates to obtain the information authorized above.