ENERGY SERVICES GROUP, INC.
APPLICATION FOR EMPLOYMENT
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? YESNO
Accident Record for the Past 3 Years
Straight Truck, Tractor & Tanker, Tractor/Trailer Combo, Other
List All Traffic Fines and Forfeitures for the Past 3 Years
Cooper Natural Resources, Inc.
TO BE READ AND SIGNED BY THE APPLICANT
Energy Services Group, Inc.
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 ______________________
THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service
In connection with your application for employment with Energy Services Group, Inc. (“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 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 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
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 days 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.
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. You may challenge the accuracy of the data by submitting a request to
https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this
data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.
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 Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law
will also appear, and remain, on a PSP report.
The Prospective Employer cannot obtain background reports from FMCSA without your authorization.
If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:
I authorize Energy Services Group, Inc. (“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 authorizing the release of safety performance information including crash data from 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.
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 challenge 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.
I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report,
or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes
were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my
PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and
remain, on my PSP report.
I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I
sign this Disclosure and Authorization, 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.
NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of Transportation,
Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant’s written
or electronic consent prior to accessing the Applicant’s PSP report. Further, account holders are required by FMCSA to use the
language contained in this Disclosure and Authorization form to obtain an Applicant’s consent. The language must be used in whole,
exactly as provided. Further, the language on this form must exist as one stand-alone document. The language may NOT be included
with other consent forms or any other language.
NOTICE: The prospective employment concept referenced in this form contemplates the definition of “employee” contained at 49