Application Job Description Mechanic

Overview: To repair company equipment in a safe, timely, cost effective and practical manner.

Essential Job Functions: Build, rebuild, and repair all parts of automotive and drilling equipment as may be required. Diagnose any mechanical, electrical or other breakdown or failure to a motor truck, drilling rigs, or related equipment both in the Shop and on the job location. Troubleshoot and perform failure analysis of the component parts and systems on the truck and drilling rig. When applicable, use welding skills and knowledge of metals to complete truck and drill repairs. When necessary, work away from home, to repair breakdowns. Perform occasional lifting, pulling, pushing and carrying of materials. Maintain records of fuel purchases, mileage records and any other records as required by the Company.

I understand the description of this job and the essential functions, as given above. I also understand that all of the duties are not described above and that I will perform those above and other related duties as directed by my supervisor and other management.

Signature *

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Print Name *

Date *

Employment Application Form

L J HUGHES & SONS, Inc.

320 Turnpike Road – Summersville, WV 26651

Please fill out this application to the best of your ability.

We are an equal opportunity employer.

We do not discriminate on the basis of race, religion, religion, color, sex, age, national origin, disability, veteran status, or any other status or condition protected by federal or state laws.

Full Name *

Is any additional information necessary to enable a check on your work record relative to change of name, nickname, ect.?

If so, explain

Address *

City *

State *

Postal code *

Social Security Number *

Phone *

Position Applied For: *

Basic Information:

Do you have a valid Driver's License? *

Yes

If your answer is no, there is no need to continue

Can you drive a standard? *

Yes

Are you willing to obtain your CDL License within the first six months of hire? *

Yes

Are you currently employed? *

Yes

May we contact your previous employer? *

Yes

N/A

Are you currently in “layoff” status, subject to recall? *

Yes

Have you ever been employed with us before? *

Yes

When?

Have you ever applied to us before? *

Yes

When?

When could you start employment with us? *

Can you perform the essential job functions of the job to which you are applying? *

Yes

Can you provide proof of identification and proof of eligibility to work in this country (for example: green card, social security card, passport, etc.) *

Yes

If required, are you available to travel and stay away from home at least a week at a time? *

Yes

Education:

Please include: the school name, location, diploma/degree received or general studies below

Elementary *

High School *

College *

Trade School *

Military History:

Job Related Training *

Current Status *

Any Specialized Training:

Any specialized training, apprenticeship programs, or any special job-related skills: *

In the event of an emergency, who are we to notify?

Name *

Address *

Phone No. *

Maintenance/Shop Experience Qualifications

List courses and equipment in maintenance work: *

Job Function

Indicate Training and Experience In:

Drive Line Components *

Formal Training?
Years of Experience:

Diesel Tune-up/Rebuild *

Formal Training?
Years of Experience:

Gas Tune-up/Rebuild *

Formal Training?
Years of Experience:

Tire Service *

Formal Training?
Years of Experience:

Inspection/Gen. Repair *

Formal Training?
Years of Experience:

Body Work *

Formal Training?
Years of Experience:

Electrical Repair *

Formal Training?
Years of Experience:

Brakes *

Formal Training?
Years of Experience:

Shop Equipment

Indicate Training and Experience In:

Electrical Diagnostic *

Formal Training?
Years of Experience:

Engine Rebuilding *

Formal Training?
Years of Experience:

Electric Welder *

Formal Training?
Years of Experience:

Oxyacetylene Welder *

Formal Training?
Years of Experience:

Tire Servicing *

Formal Training?
Years of Experience:

Engine Analysis *

Formal Training?
Years of Experience:

Paint Spray Gun *

Formal Training?
Years of Experience:

Driver Information:

Date of birth *

(The US DOT requires that driver applicants state their date of birth.)

Have you ever been convicted of a felony? Conviction will not automatically disqualify you. *

Yes

Have you ever been denied a license, permit or privilege to operate a motor vehicle? *

Yes

Has any driver license, permit or privilege ever been suspended or revoked? *

Yes

Year of suspension or revocation:

Have you ever been disqualified for violations of the “Federal Motor Carrier Safety Regs.”? *

Yes

Date of last DOT prescribed physical examination. *

Would you object to a drug test today? *

Yes

Have you ever been granted a waiver under the Federal Motor Carrier Safety Regulations pertaining to the loss of a foot, leg, hand or arm? *

Yes

Driver Experience & Qualification:

Driver License Information *

State
License No.
Type
Expiration Date
State
License No.
Type
Expiration Date
State
License No.
Type
Expiration Date

Driver Experience *

Class of Equipment
Type of Equipment (Van, Tank, Flat, ect.)
Dates (From/To)
Approx. # of Miles (Total)
Class of Equipment
Type of Equipment (Van, Tank, Flat, ect.)
Dates (From/To)
Approx. # of Miles (Total)
Class of Equipment
Type of Equipment (Van, Tank, Flat, ect.)
Dates (From/To)
Approx. # of Miles (Total)

Accident Review of the Last 3 Years *

Date
Nature of Accident (Head-On, Rear-End, Upset, etc.)
Fatalities
Injuries
Date
Nature of Accident (Head-On, Rear-End, Upset, etc.)
Fatalities
Injuries
Date
Nature of Accident (Head-On, Rear-End, Upset, etc.)
Fatalities
Injuries
Date
Nature of Accident (Head-On, Rear-End, Upset, etc.)
Fatalities
Injuries

Traffic Convictions and Forfeitures for the Past 3 Years (other than parking violations) *

Location
Date
Charge
Penalty
Location
Date
Charge
Penalty
Locations
Date
Charge
Penalty

Driver Licenses (Driver Licenses held in the last 3 years must be shown)

List states in which you have driven truck for in the last five years. *

Please describe any discrepancies or concerns with employment, driving record or other areas. *

Employment History:

Please begin with your current or last job. Include military service assignments. If you include volunteer activities, please exclude organizations that might indicate race, color, religion, national origin, disability or other protected status.

(1) *

Employer
Address
Phone No.
Duties and Responsibilities
From
To
Hourly/Yearly Wages (Starting)
Hourly/Yearly Wages (Ending)
Job Title
Supervisor
Reason for Leaving
Reason for Leaving (Continued)

DOT Regulated: *

Yes

DOT Safety Sensitive Position which required Drug and Alcohol Testing: *

Yes

(2)

Employer
Address
Phone No.
Duties and Responsibilities
From
To
Hourly/Yearly Wages (Starting)
Hourly/Yearly Wages (Ending)
Job Title
Supervisor
Reason for Leaving
Reason for Leaving (Continued)

DOT Regulated:

Yes
No

DOT Safety Sensitive Position which required Drug and Alcohol Testing:

Yes

(3)

Employer
Address
Phone No.
Duties and Responsibilities
From
To
Hourly/Yearly Wages (Starting)
Hourly/Yearly Wages (Ending)
Job Title
Supervisor
Reason for Leaving
Reason for Leaving (Continued)

DOT Regulated:

Yes

DOT Safety Sensitive Position which required Drug and Alcohol Testing:

Yes

The US DOT requires that applicants for driving positions must advise prospective employers of positions held as a commercial driver during the past 10 year period. This space is being provided for that purpose.

(1) *

Employer
Address
Phone No.
From
To
Hourly/Yearly Wages (Starting)
Hourly/Yearly Wages (Ending)
Job Title
Supervisor
Reason for Leaving
Reason for Leaving (Continued)

(2)

Employer
Address
Phone No.
From
To
Hourly/Yearly Wages (Starting)
Hourly/Yearly Wages (Ending)
Job Title
Supervisor
Reason for Leaving
Reason for Leaving (Continued)

(3)

Employer
Address
Phone No.
From
To
Hourly/Yearly Wages (Starting)
Hourly/Yearly Wages (Ending)
Job Title
Supervisor
Reason for Leaving
Reason for Leaving (Continued)

(4)

Employer
Address
Phone No.
From
To
Hourly/Yearly Wages (Starting)
Hourly/Yearly Wages (Ending)
Job Title
Supervisor
Reason for Leaving
Reason for Leaving (Continued)

(5)

Employer
Address
Phone No.
From
To
Hourly/Yearly Wages (Starting)
Hourly/Yearly Wages (Ending)
Job Title
Supervisor
Reason for Leaving
Reason for Leaving (Continued)

References other than previous employers and relatives:

Reference 1 *

Name
Phone Number
Address

Reference 2

Name
Phone Number
Address

Reference 3

Name
Address
Phone Number

Previous Address if you have not lived at your current address for three years:

Applicant’s Acknowledgment (Please read before signing.)

I certify that answers given in this application are true and complete to the best of my knowledge. I authorize investigation into all statements I have made on this application as may be necessary for reaching an employment decision.

As a condition of my employment, I accept the principle that the welfare of the organization depends upon the conduct and honesty of its employees and the trust and confidence of our customers and the public in general. The organization expects honesty, security and confidentiality. I therefore agree to the following:

1. I agree to give no unauthorized information relative to the accounts of the organization or its relation with others, and to discuss no matters of a confidential nature relating to the organization’s affairs unless such discussion is in the necessary course of the organization’s business and is in accord and with the organization’s policy

2. I also agree to inform the management of the organization, without delay, of any fraud, false entry, substantial error, embezzlement or employee misconduct, which I discover or know to have taken place in any records, property, or funds of the organization, and to report any transaction or matter that seems damaging to the organization.

3. In the event I am employed, I understand that any false or misleading information I knowingly provided in my application or interview(s) may result in discharge and/or legal action. I understand also that if employed, I am required to abide by all the rules and regulations of the employer and any special agreements reached by the employer and me.

This application shall be considered active for no more than six months. After that time, applicants will be required to resubmit a completed application. The applicant understands that neither this document nor any offer of employment from this employer constitutes an employment contract unless the employer and employee execute a specific document in writing. Any oral or written statements to the contrary are hereby expressly disavowed and should not be relied upon. Unless a specific document is executed in writing by the employer and employee, All Employment Here Is At -Will. Just as an employee may resign for any reason he/she has, the employer may also terminate an employee for any reason.

Signature of Applicant *

Clear

Today's Date *

Voluntary Employee Information Regarding References and Background Investigation

(This information does not have to be completed.)

Do not provide personal information that is not clearly relevant to your potential employment. If you have questions about whether the information is relevant, please contact Employer and ask whether you should provide information on the general topic of concern, without revealing any specifics.

I have the following special concerns and/or comments about potentially negative references or information that may be revealed through Employer’s background investigation regarding:

Previous Employment Information

Educational Information

Personal References

Licensing or Certification Information

Criminal Records (Do not provide information about arrests for criminal offenses unless you were convicted. Do not provide information about marijuana-related convictions more than two years old.)

Credit Report

Other

If you checked "other", please provide details:

My concerns or comments about potentially negative references or information relevant to my potential employment are:

Dated

Employee Signature

Clear

Release and Authorization for Background

and Reference Investigation

As part of its employment screening and selection procedures, the Employer or potential employer, named below, requires a background investigation and a check of references. Such investigation and checks may require the submission to the Employer of information about the applicant’s social security number (SSN), date of birth (DOB) and driver’s license number (DL).

, hereby give the Employer and/or its designees permission and authority to conduct a background investigation and reference checks concerning my past and current activities. I agree and consent to any investigation the Employer and/or its designees may make including, but not limited to, information as to my personal character, general reputation, former employment, education, credit history, driving record, social security wage information, criminal history and other information contained in public records or obtainable from former employers or other references, business or personal. It is also agreed and understood that under the Fair Credit Reporting Act (Public Law 91-508) I have been told that this investigation may take place.

I hereby consent, authorize and request any former employers, personal references, schools, police and court personnel, credit agencies and any other person to respond to verbal or written inquiries from Employer and/or its designees and to disclose information concerning:

1. My previous employment record, including but not limited to positions held, dates of employment, last pay rate, work performance, disciplinary records, reliability and any incidents of dishonesty, insubordination, violence, and/or unsafe, harmful or threatening behavior, or other relevant information, including information based upon information in my personnel files;

2. My educational records from any and all public or private educational institutions that I have attended including all records of my academic performance, courses attended, grades earned, diplomas, degrees, other certificates conferred, or other relevant information;

3. My general background and I specifically request, authorize and consent to Employer’s verbal or written inquiries of personal references about the information contained in my application, as well as my reliability, honesty and potential tendency, if any, to engage in any form of violence, and/or unsafe, harmful or threatening behavior, or other relevant information.

4. My professional or vocational license or certification that I may have held in the past or may currently hold, including, but not limited to, information concerning whether such license or certification is in good standing and any disciplinary or other proceedings concerning such license or certification, or other relevant information;

5. Whether I have a record of criminal convictions, and, if so, the nature of such criminal convictions and all surrounding circumstances available through lawful means. Employer has advised me that its criminal background check will focus on convictions and that a criminal record will not necessarily disqualify me from employment;

6. My credit history and I understand that the results of a background check of my credit records will be used as part of the evaluation of my application and that both verbal and written reports will be obtained from the reporting service. I also understand that I may receive such information by making a written request to the credit-reporting agency. To receive any of this information or access to my records, I realize that I must submit proper identification with my request. (Employer will not deny employment solely on the basis that an applicant has filed bankruptcy.)

I hereby release all persons, companies, corporations or individuals from all liability and responsibility that may result from providing Employer and/or its designees the information set out herein, including but not limited to, any claims whatsoever for defamation, fraud, misrepresentations, intentional or negligent interference with prospective business relations or contract, breach of contract (including any settlement agreement), negligent or intentional infliction of emotional distress, employment discrimination, violation of public policy, and any other potential claims, demands, damages, liabilities and/or actions of any kind whatsoever, whether known or unknown to me presently or in the future. I have voluntarily explained any concerns about the information that may be provided to Employer during this process in writing on the attached document entitled “Voluntary Employee Information Regarding Background and Reference Investigation.”

I am aware that the result of any background investigation performed by Employer and/or its designees is not the sole criteria used by the Employer in making a decision to hire or not hire any individual, including me. I am also aware that any falsification or misrepresentation of information appearing on my application for employment shall be grounds for my not being hired or for my being terminated.

Potential Employer *

Applicant *

Social Security No. *

Drivers License No. *

State of Issue *

The Date: *

Applicant's Signature *

Clear