Date:

First
Middle
Last		  

Home Address
City
Zip

Home Phone
Social Security
Drivers License Number

Cell Phone
Date Of Birth
State Of Issue/Class

Position Desired
Salary Desired
Date You Can Start?

How Did you Hear of Us?
Compensation of Last Job?		  
Are you 18 years of age or older? YES NO
Have you ever had an "At Fault" accident while on the job? YES NO
If yes, explain:
Number of speeding tickets in the last 3 years?
Have you ever been injured on the job? YES NO
What was the outcome of your injuries?
Are you prevented from becoming lawfully employed due to immigration status? YES NO
Have you ever been convicted of a felony? YES NO
If Yes, what date were you charge? Date:
Are you currently on probation? YES NO
Are you currently employed? YES NO
If so, may we contact your employer? YES NO


Employment History

Dates From: To:
NAME OF COMPANY:
ADDRESS:
PHONE:
POSITION:
RATE OF PAY:
DUTIES:
REASON FOR LEAVING:
MAY WE CONTACT THIS EMPLOYER? YES    NO

2

Dates From: To:
NAME OF COMPANY:
ADDRESS:
PHONE:
POSITION:
RATE OF PAY:
DUTIES:
REASON FOR LEAVING:
MAY WE CONTACT THIS EMPLOYER? YES    NO

3

Dates From: To:
NAME OF COMPANY:
ADDRESS:
PHONE:
POSITION:
RATE OF PAY:
DUTIES:
REASON FOR LEAVING:
MAY WE CONTACT THIS EMPLOYER? YES    NO

Highschool

DATES: From: To:
NAME OF SCHOOL
ADDRESS:
DID YOU GRADUATE: YES    NO
If yes what year?
If no, did you receive a GED? YES    NO

COLLEGE

DATES: From: To:
NAME OF SCHOOL
ADDRESS:
DID YOU GRADUATE: YES    NO
If no, how many hours have you completed?

SKILLS ABILITIES
PLEASE LIST ANY SPECIAL SKILLS, ABILITIES, AND/OR EQUIPMENT YOU CAN OPERATE THAT MIGHT BE APPLICABLE TO THE POSITION YOU ARE APPLYING FOR.

SKILLS

 
EQUIPMENT

 

I certify that all the information submitted by me on this application is true and complete, and I understand that if any information, omissions, or misrepresentations are discovered my application may be rejected; and if I am employed my employment may be immediately terminated In consideration of discovered, and, employed, terminated. my employment, I agree to conform to the company's rules and regulations and agree that the terms and conditions of my employment may be changed with or without cause and with or without notice at any time by M&D Foundation Drilling Industries, Inc. I hereby give M&D Foundation Drilling Industries permission to obtain copies of my Motor Vehicle Records from any state where I am or have been a licensed driver, and to receive any information from my previous employers which may be pertinent to my employment.