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Applicant Information

Name:

Email:

Phone:

Address:

City:

Zip Code:

Position Applying For?

Date Available to Start:

Current Employment Status:

Employed

Unemployed

Self-Employed

Student

Desired Salary:

Are you a U.S. Citizen?

Yes

If no, are you authorized to work in the U.S?

Yes

Have you ever worked for this company?

Yes

If yes, when?

Attach Resume or Cover Letter:

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Education

High School:

Address:

From:

To:

Did you graduate / receive your GED?

Yes

College:

Address:

Do you have any special skills for the position that you are applynig for?

Yes

If yes, please list:

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References

Please list two professional references

Full Name:

Relationship:

Company:

Phone:

Address:

Full Name:

Relationship:

Company:

Phone:

Address:

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Previous Employment:

Company:

Phone:

Address:

Supervisor

Job Title

Starting Salary:

Ending Salary:

Responsibilities:

From:

To:

Reason for leaving:

May we contact your supervisor for a reference?

Yes

Company:

Phone:

Address:

Supervisor:

New Field:

Starting Salary:

Ending Salary:

Responsibilities:

From:

To:

Reason for Leaving:

May we contact your supervisor for a reference?

Yes

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Driver's License:

Do you have a current driver's license?

Yes

Job Title:

Driver's License Number:

List any restrictions:

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Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Date:

Your Initials (Digital Signature Consent):

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By checking, I agree and consent to the statements above.

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Enter your free text here

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Authorization for Reports and/or Driving Records to be obtained

Date:

Full Name:

Your Initials (Digital Signature Consent):

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I authorize the company delegated by Kelley Oilfield Services, Inc. to obtain consumer reports covered by the Federal Fair Credit Reporting Act and any comparable state laws that are applicable, as well as my driving record, covered by the federal Drivers Privacy Protection Act and comparable state laws that are applicable, to asses my insurability and/or employability and for any other legally permissible purposes. By signing this authorization, I hereby provide my consent to the Company to procure such consumer reports and driving records about me from time to time, as it deems appropriate, to evaluate my insurability and/or employability and for any other legally permissible purposes.

Driver's License Number & State:

Social Security Number:

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By checking, I agree and consent to the statements above.

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Full Name:

Date of Birth:

Social Security Number:

Address:

City:

Zip Code:

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Full Name

Date of Birth

Social Security Number

Address

New Field:

State

Zip Code

Have you ever suffered a work-related injury?

Yes

Have you ever filed and/or received Workers' Compensation Benefits?

Yes

If yes

Have you ever suffered an illness or injury other than at work where you were off work and/or had to limit your activities for more than one week?

Yes

If yes, list dates and describe all such injuries and/or illnesses suffered.

Have you ever been in an automobile accident?

Yes

If yes, list dates of all such accidents, all injuries suffered including any physical restrictions imposed.

List your family physician.

Please check any of the following activities for which you have, or have had, a restriction.

Give a brief description of any restrictions checked above.

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NOTICE: Under Section 52-1-28.3, NMSA 1978, of the New Mexico Workers' Compensation Act provides that the worker shall be entitled to NO future Workers' Compensation benefits if he or she knowingly and willfully conceals or makes a false representation about the information requested.

Please be advised that we will rely upon your answers to the above questions and that such reliance will be a substantial factor in your initial and continued employment with this company.

I hereby certify that the information listed above is true, correct and complete, to the best of my knowledge and that I understand all of the questions listed in this questionnaire. I further certify that I have read and understand the above Notice provision indicating that I will be entitled to NO future Workers' Compensation benefits if I knowingly and willfully conceal or make a false representation about the information requested.

(please make sure the questionnaire is filled out completely before signing.)

Employee Signature (Digital Signature Consent)

Your Initials (Digital Signature Consent):

Date

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By checking, I agree and consent to the statements above.

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