ROGERS PETROLEUM SERVICES Pikeville Location

After filling out Online Form Please print PDF application and Bring the Section indicated for former employer on day of interview thank you.
Applicant First Name *			Applicant Last Name *
Applicant Middle Name *			Social Security No. *
Email Address *			Date of Birth (MM/DD/YYYY) *
Telephone Number
Current Address *					How Long? (y/m)

Previous Address 1					How Long? (y/m)

Previous Address 2					How Long? (y/m)

Previous Address 3					How Long? (y/m)

Do you have the legal right to work in the United States?
Have you worked for this company before?			Where?		Dates: From		To

			Rate of Pay		Position

Reason for leaving?
Are you now employed?
If not, how long since last employment?
Who referred you?			Rate of pay expected?
Have you ever been bonded?			Name of bonding company?
Have you ever been convicted on a felony?
If yes, please explain fully on a separate sheet of paper. Conviction of a crime is not an automatic bar to employment-all circumstances will be considered
Is there any reason you might be unable to perform the functions of the job for which you have applied [as described in the attached job description]?

If yes, explain if you wish.

EMPLOYMENT HISTORY
All Driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state and zip code. Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years' information on thos employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)
EMPLOYER 1					DATE
NAME					FR:		TO:
ADDRESS					POSITION HELD
CITY	STATE		ZIP		SALARY/WAGES
CONTACT PERSON		PHONE NUMBER			REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs WHILE EMPLOYED?(YES/NO)
WAS YOUR JOB DESIGNATED AS A SAFETY-ENSITIVE FUNCTION IN ANY DOT-REGULATE MODE SUBJECT TO THEDRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? (YES/NO)

EMPLOYER 2					DATE
NAME					FR:		TO:
ADDRESS					POSITION HELD
CITY	STATE		ZIP		SALARY/WAGES
CONTACT PERSON		PHONE NUMBER			REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs WHILE EMPLOYED?(YES/NO)
WAS YOUR JOB DESIGNATED AS A SAFETY-ENSITIVE FUNCTION IN ANY DOT-REGULATE MODE SUBJECT TO THEDRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? (YES/NO)

EMPLOYER 3					DATE
NAME					FR:		TO:
ADDRESS					POSITION HELD
CITY	STATE		ZIP		SALARY/WAGES
CONTACT PERSON		PHONE NUMBER			REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs WHILE EMPLOYED?(YES/NO)
WAS YOUR JOB DESIGNATED AS A SAFETY-ENSITIVE FUNCTION IN ANY DOT-REGULATE MODE SUBJECT TO THEDRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? (YES/NO)

EMPLOYER 4					DATE
NAME					FR:		TO:
ADDRESS					POSITION HELD
CITY	STATE		ZIP		SALARY/WAGES
CONTACT PERSON		PHONE NUMBER			REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs WHILE EMPLOYED?(YES/NO)
WAS YOUR JOB DESIGNATED AS A SAFETY-ENSITIVE FUNCTION IN ANY DOT-REGULATE MODE SUBJECT TO THEDRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? (YES/NO)

EMPLOYER 5					DATE
NAME					FR:		TO:
ADDRESS					POSITION HELD
CITY	STATE		ZIP		SALARY/WAGES
CONTACT PERSON		PHONE NUMBER			REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs WHILE EMPLOYED?(YES/NO)
WAS YOUR JOB DESIGNATED AS A SAFETY-ENSITIVE FUNCTION IN ANY DOT-REGULATE MODE SUBJECT TO THEDRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? (YES/NO)

EMPLOYER 6					DATE
NAME					FR:		TO:
ADDRESS					POSITION HELD
CITY	STATE		ZIP		SALARY/WAGES
CONTACT PERSON		PHONE NUMBER			REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs WHILE EMPLOYED?(YES/NO)
WAS YOUR JOB DESIGNATED AS A SAFETY-ENSITIVE FUNCTION IN ANY DOT-REGULATE MODE SUBJECT TO THEDRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? (YES/NO)

EMPLOYER 7					DATE
NAME					FR:		TO:
ADDRESS					POSITION HELD
CITY	STATE		ZIP		SALARY/WAGES
CONTACT PERSON		PHONE NUMBER			REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs+ WHILE EMPLOYED?(YES/NO)
WAS YOUR JOB DESIGNATED AS A SAFETY-ENSITIVE FUNCTION IN ANY DOT-REGULATE MODE SUBJECT TO THEDRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? (YES/NO)
* Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding. + The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in requiring placarding.

ACCIDENT RECORD FOR THE PAST 3 YEARS OR MORE(EMAIL IF MORE SPACE IS NEEDED) IF NONE, WRITE NONE
DATES	NATURE OF ACCIDENT (HEAD-ON,REAR-END,UPSET,ETC)		FATALITIES		INJURIES		HAZARDOUS MATERIAL SPILL
LAST ACCIDENT
NEXT PREVIOUS
NEXT PREVIOUS

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE
LOCATION		DATE	CHARGE		PENALTY




DRIVER LICENSES	STATE	LICENSE NO.	TYPE	EXPIRATION DATE



A. Have you ever been denied a license,permit or privilege to operate a motor vehicle?
B. Has any license, permit or privilege ever been suspended or revoked?
IF THE ANSWER TO EITHER A OR B IS YES , GIVE DETAILS

			DATES			APROX. NO. OF MILES (TOTAL)
DRIVING EXPERIENCE(TYPE YES OR NO)		TYPE OF EQUIPMENT	TO(M/Y)	FROM(M/Y)
STRAIGHT TRUCK
TRACTOR AND SEMI-TRAILER
TRACTOR-TWO TRAILERS
TRACTOR-THREE TRAILERS
MOTORCOACH-SCHOOLBUS (more than 8 passengers)
MOTORCOACH-SCHOOLBUS (more than 15 passengers)
OTHER

LIST STATES OPERATED IN FOR LAST FIVE YEARS:
SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER
WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM?
EXPERIANCE AND QUALIFICATIONS
SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY
LIST COURSES AND TRAINING OTHER THAT SHOWN ELSEWHERE IN THIS APPLICATION:
LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN)
HIGHEST GRADE COMPLETED		ELEMENTARY	HIGH SCHOOL	COLLEGE

LAST SCHOOL ATTENDED
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