Last Name
First Name
Middle Name
Date Of Birth
Street Address
City
State
Zip
Drivers License #
Social Security #
Email
Telephone
Have You Ever Been Employed By Empire Gas Services, LLC?
YesNo
Date
Location
Position
Position Applied For
Minimum Hourly Pay Expected
Are you 18 years or older?
yesno
Are you available for full time work?
Hours Desired
Location Desired
When will you be able to begin?
Are you legally eligible for employment in the US?
YesNo Proof of citizenship or immigration status will be required upon employment
Will you work overtime when asked?
Are any of your relatives presently employed by Empire Gas Services?
YesNo If so, who?
Where did you hear about us?
Job Fairplantjobs.infoNewspaper/Print AdSchool/College ReferralEmployment AgencyDept Of Labor/Job ServiceWalk-In
High School and Location
Years Completed
Did You Graduate? YesNo
Degree
College Attended and Location
Trade/Business/Technical School & Location
Licenses/Certifications
Expiration Date
Other Special Training or skills (Languages, Machine Operations, Computer Skills, ETC.)
(ANSWERING YES TO THESE QUESTIONS MAY DISQUALIFY YOU FROM EMPLOYMENT.)
Have you ever been convicted of a crime other than a minor misdemeanor or traffic offense?
YesNo If so, when and nature of offense? Date
Have you ever been convicted of driving while intoxicated?
YesNo If yes, when?
Have you used any illegal drugs in the last two years?
Have you ever been convicted of illegal drug use or sale?
Company Name
Address (Number, Street, City, State, ZIP Code)
Phone
Date Employed (Day, Month, Year)
Date Left (Day, Month, Year)
Awards Received
May we contact?
Supervisor Name
Supervisor Phone
Starting Hourly Pay
Final Hourly Pay
Reason for Leaving
THIS JOB MAY REQUIRE THAT YOU ARE AVAILABLE TO WORK ON WEEKENDS, HOLIDAYS, AND VARIED SHIFTS DURING THE WEEK, CAN YOU MEET THESE ATTENDANCE REQUIREMENTS?
HAVE YOU WORKDED A JOB THAT INVOLVED A ROTATING DAY & NIGHT SHIFT?
HOW MANY DAYS OF LEAVE DID YOU TAKE LAST YEAR, EXCLUDING AUTHORIZED VACATION?
DID YOU HAVE ANY UNAUTHORIZED ABSENCES FROM YOUR JOB LAST YEAR?
HOW MANY MONDAYS OR FRIDAYS WERE YOU ABSENT LAST YEAR OR ON LEAVE OTHER THAN APPROVED VACATION? NOTE: MONDAYS AND FRIDAYS ARE CONSIDERED THE DAY IMMEDIATELY PRIOR TO AND FOLLOWING YOUR REGULARLY SCHEDULED DAYS OFF.
DO YOU HAVE RELIABLE TRANSPORTATION TO AND FROM WORK FOR REQUIRED SHIFTS AND PRTENTIAL OVERTIME SHIFTS AT ALL TIMES?
DO YOU HAVE A VALID DRIVER’S LICENSE?
IF YES, DRIVER’S LICENSE NUMBER
STATE OF ISSUE
DO YOU HAVE A RELIABLE VEHICLE AVAILABLE FOR YOUR USE AT ALL TIMES?
DO YOU HAVE A TWIC?
DO YOU HAVE A MERCHANT MARINER’S DOCUMENT?
YesNo IF YES, DOCUMENT#
TANKERMAN’S ENDORSEMENT?
YesNo Grade Date of Issue
HAVE YOU EVER BEEN ISSUED A CITATION OR WARNING, OR HAS THE UNITED STATED COAST GUARD OR ANY OTHER ADMINISTRATIVE OR REGULATORY AGENCY EVER TAKEN ANY ADMINISTRATIVE ACTION?
IF YES, GIVE BRIEF DETAILS.
U.S.MILITARY ECPERIENCE?
IF YOUR DUTIES WERE RELATED TO THE JOB FOR WHICH YOU ARE NOW APPLYING, PLEASE DESCRIBE THOSE DUTIES. From:To:
I CERTIFY THAT THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
IF EMPLOYED, ANY MISSTATEMENT OR OMISSION OF FACT ON THIS APPLICATION MAY RESULT IN MY DISMISSAL.
I UNDERSTAND FAILURE TO COME TO WORK ON TIME, LEAVING EARLY, AND MISSING WORK CAN RESULT IN MY DISMISSAL OF THE JOB.
I UNDERSTAND THAT COMPLETION OF THE APPLICATION DOES NOT CONSTITUTE AN OFFER OF EMPLOYMENT AND SUPERSEDES ANY AGREEMENTS OR UNDERSTANDINGS BETWEEN THE APPLICANT AND EMPIRE GAS SERVICES, LLC. THIS APPLICATION WILL REMAIN VALID FOR SIX MONTHS. I FURTHER UNDERSTAND THAT EMPIRE GAS SERVICES, LLC IS AN AT WILL EMPLOYER AND THAT SHOULD AN OFFER OF EMPLOYMENT BE EXTENDED TO AND ACCEPTED BY ME THAT THIS OFFER OF EMPLOYMENT DOES NOT CREATE A CONTRACTUAL OBLIGATION OF THE EMPLOYER TO CONTINUE TO EMPLOY ME IN THE FUTURE.
I HEREBY AUTHORIZE MY PRESENT AND/OR PAST EMPLOYERS TO RELEASE ALL INFORMATION REGARDING MY EMPLOYMENT. I FURTHER AGREE THAT I WILL NOT HOLD MY PRESENT OR FORMER EMPLOYERS LIABLE FOR ANY INFORMATION RELEASED TO EMPIRE GAS SERVICES, LLC REGARDING MY EMPLOYMENT HISTORY.
I have read & Agree Signature Date
Please leave this field empty.
