ENERGY SERVICES GROUP, INC.
APPLICATION FOR EMPLOYMENT

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Add Additional Employer? YESNO

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DRIVER STATEMENT OF ON-DUTY HOURS
(For Newly Hired Drivers)

INSTRUCTIONS: Motor carriers when using a driver for the first time shall obtain from the driver a signed statement giving the total time on-duty during the immediately preceding 7 days and time at which such driver was last relieved from duty prior to beginning work for such carrier. Rule 395.8(j)(2) Federal Motor Carrier Safety Regulations. NOTE: Hours for any compensated work during the preceding 7 days, including work for a non-motor carrier entity, must be recorded on this form.

I hereby certify that the information given above is correct to the best of my knowledge and belief, and that I was last relieved from work at

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DRIVER CERTIFICATION FOR OTHER COMPENSATED WORK

INSTRUCTIONS: When employed by a motor carrier, a driver must report to the carrier all on-duty time including time working for other employers. The definition of on-duty time found in Section 395.2 paragraphs (8) and (9) of the Federal Motor Carrier Safety Regulations includes time performing any other work in the capacity of, or in the employ or service of, a common, contract or private motor carrier, also performing any compensated work for any nonmotor carrier entity.

 

 

 

I hereby certify that the information given above is true and I understand that once I become employed with this company, if I begin working for any additional employer(s) for compensation that I must inform this company immediately of such employment activity.

 

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SAFETY PERFORMANCE HISTORY RECORDS REQUEST

Hereby authorize:

To release and forward the information requested by section 3 of this document concerning my Alcohol and Controlled Substances Testing records within the previous 3 years from

 

To:
Energy Services Group, Inc.
HSE Manager - 817-244-9700
7755 Bellaire Drive South
Ft. Worth, TX 76132

 

In compliance with §40.25(g) and 391.23(h), release of this information must be made in a written form that ensures confidentiality, such as fax, email, or letter.
Prospective employer's fax number: 817-244-9701

This information is being requested in compliance with §40.25(g) and 391.23.

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ACCIDENT HISTORY

The applicant named above was employed by us. Yes ☐ No ☐
Employed as __________________________ from (m/y) ______________________ to (m/y) ______________________

1. Did he/she drive motor vehicle for you? Yes ☐ / No ☐ If yes, what type? Straight Truck ☐
Tractor-Semitrailer ☐ Bus ☐ Cargo Tank ☐ Doubles/Triples ☐ Other (Specify) ________________________________________________

2. Reason for leaving your employ: Discharged ☐ Resignation ☐ Lay Off ☐ Military Duty ☐
If there is no safety performance history to report, check here ☐, sign below and return.

ACCIDENTS: Complete the following for any accidents included on your accident register (§390.15(b)) that involved the applicant in the 3 years prior to the application date shown above, or check ☐ here if there is no accident register
data for this driver.

Please provide information concerning any other accidents involving the applicant that were reported to government agencies or insurers or retained under internal company policies:
__________________________________________________________________________________________________ __________________________________________________________________________________________________
__________________________________________________________________________________________________
Any other remarks:
__________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________

Signature: _________________________________________ Title: ______________________________ Date: ____________________

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Add Additional Request? YESNO

DRUG AND ALCOHOL HISTORY

If driver was not subject to Department of Transportation testing requirements while employed by this employer, please check here ☐ , fill in the dates of employment from _______________ to _______________, complete bottom of Part 3, sign, and return.

Driver was subject to Department of Transportation testing requirements from _______________ to _______________.

1. Has this person had an alcohol test with the result of 0.04 or higher alcohol concentration? YES ☐ NO ☐

2. Has this person tested positive or adulterated or substituted a test specimen for controlled substances? YES ☐ NO ☐

3. Has this person refused to submit to a post-accident, random, reasonable suspicion, or follow-up alcohol or controlled substance test? YES ☐ NO ☐

4. Has this person committed other violations of Subpart B of Part 382, or Part 40? YES ☐ NO ☐

5. If this person has violated a DOT drug and alcohol regulation, did this person complete a SAP-prescribed rehabilitation program in your employ, including return-to-duty and follow-up tests? If yes, please send documentation back with this form. YES ☐ NO ☐

6. For a driver who successfully completed a SAP’s rehabilitation referral and remained in your employ, did this driver subsequently have an alcohol test result of 0.04 or greater, a verified positive drug test, or refuse to be tested? YES ☐ NO ☐

In answering these questions, include any required DOT drug or alcohol testing information obtained from prior previous employers in the previous 3 years prior to the application date shown on page 1.

Name: ___________________________________________________________________________________________
Company: ________________________________________________________________________________________
Street: ___________________________________________________________________________________________
City, State, Zip: ____________________________________________________ Telephone: _____________________
Part 3 Completed by (Signature): ___________________________________________ Date: _____________________

This form was (check one) ☐ Faxed to previous employer ☐ Mailed ☐ Emailed ☐ Other __________________

By: __________________________________________________________________ Date: ______________________

Complete below when information is obtained.

Information received from: ____________________________________________________________________________

Recorded by: _______________________________________ Method: ☐ Fax ☐ Mail ☐ Email ☐ Telephone

Date: _____________________________________________ ☐ Other _____________________________________

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.

Date:
Applicant Signature:

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FOR COMPANY USE

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

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THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL
ACCOUNT HOLDERS

IMPORTANT NOTICE
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

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 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 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 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.

 

AUTHORIZATION

 

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:
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 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.

 

DATE:
SIGNATURE:

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(FMCSA) Drug and Alcohol Clearinghouse Release of Information

General Consent for Limited Queries of the Federal Motor Carrier Safety Administration Drug and Alcohol Clearinghouse

I, , hereby provide consent to Energy Services Group, Inc. to conduct a limited query of the FMCSA Commercial Driver’s License Drug and Alcohol Clearinghouse to determine whether drug or alcohol violation information about me exists in the Clearinghouse.

I understand that if the limited query conducted by Energy Services Group, Inc indicates that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information to Energy Services Group, Inc. without first obtaining additional specific consent from me.

I further understand that if I refuse to provide consent for Energy Services Group, Inc. to conduct a limited query of the Clearinghouse, Energy Services Group, Inc. must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle as required by FMCA’S drug and alcohol program regulations.

Date:
Applicant Signature: