EmailMe Form - Gas Well Security Pre-Application Form

Name

First Middle Last

Maiden or Former Last Names

Address

Street Address City State / Province / Region Postal / Zip Code

Home Phone

### - ### - ####

Cell Phone

### - ### - ####

Email

For Background Check

Have you ever been convicted of a criminal offense (felony or misdemeanor)? If yes, please explain

Date of Birth

MM / DD / YYYY

City of Birth

Driver's License Number and Expiration and State

Gender

Employment Position

Position Applying For

Desired Salary

Full Time or Part time?

Would you be available for overtime?

Days and Hours Available?

How did you hear about this job?

Education, Training and Experience

High School Name, address

Number of Years completed? Did you Graduate? What year?

College/Vocational Schoole Continuing Education Name/Address

Number of Years completed? Did you Graduate? What year?

Military

Branch and service dates

Skills and Duties

Rank at Discharge and Type of discharge

If other than honorable, please explain

References - list three professional referneces (non family members) - include phone and relationship and years known

Personal Information

Have you every applied or worked at GWS? If so, when?

Do you have any friends or relatives working for GWS? If so, give name and relationship.

Previous Employment

Please describe past and present employment positions, dating back five years or four jobs (whichever is greater). Please account for all periods of employment. Even if you are attaching a resume, this section must be completed!

Name, Address of employer. Include supervisors name, phone, and job title.

Please enter ending salary, job duties and length of employment, as well as reason for leaving.

May we contact this employer?

Name, Address of employer. Include supervisors name, phone, and job title.

Please enter ending salary, job duties and length of employment, as well as reason for leaving.

May we contact this employer?

Name, Address of employer. Include supervisors name, phone, and job title.

Please enter ending salary, job duties and length of employment, as well as reason for leaving.

May we contact this employer?

Name, Address of employer. Include supervisors name, phone, and job title.

Please enter ending salary, job duties and length of employment, as well as reason for leaving.

May we contact this employer?

Additional Information - Do you have any other experience, training, qualifications, or skills which you feel should be brought to our attention, in the case that they make you especially suited for working with us?

Please Read Each Paragraph, Submission of this application assumes agreement with these conditions. I certify that I have not purposely withheld any information that might adversely affect my chances for hiring. I attest to the fact that the answers given by me are true & correct to the best of my knowledge and ability. I understand that any omission (including any misstatement) of material fact on this application or on any document used to secure can be grounds for rejection of application or, if I am employed by this company, terms for my immediate expulsion from the company.

I understand that if I am employed, my employment is not definite and can be terminated at any time either with or without prior notice, and by either me or the company.

I permit the company to examine my references, record of employment, education record, and any other information I have provided. I authorize the reference I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release the company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such examination or revelation.