POWERS OIL COMPANY LTD. Dba Powers Oil & Propane EMPLOYMENT APPLICATION1. Employer InformationEmployer: Powers Oil Ltd. Address: 1681 West Main St. Telephone: 330-821-8387 City/State/ZIP: Alliance, Ohio 446012. Applicant InformationApplicant Name(Required) First Last Applicant Email(Required) Applicant Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Years at this Address(Required) (If less than 3 years provide additional addresses)Additional Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Daytime Phone(Required)Evening PhoneDriver's License(Required) (State, Number, Expiration)3. Emergency ContactEmergency Contact Name(Required) First Last Relationship to you(Required) Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Daytime Phone(Required)Evening Phone4. Job Position Applied ForDesired Salary(Required) Who referred you to our company? Have you been a licensed driver for at least 5 years?(Required) Yes No If applicable, are you able to work overtime?(Required) Yes No If offered employment, when would you be available to begin work?(Required) MM slash DD slash YYYY Are you legally eligible for employment in the United States?(Required) Yes No Are you able to perform the essential functions of the job for which you are applying with reasonable accommodations, including those that require moderate to heavy lifting?(Required) Yes No Have you ever been convicted of any crime, including traffic violations?(Required) Yes No Please describe (include min. past 3 yrs., date of conviction, offense, location, type of motor vehicle operated) Have you ever been involved in any traffic accidents/crashes?(Required) Yes No Please describe (include min. past 3 yrs., nature of accident, and if any fatalities or personal injuries resulted Have you ever had a denial, revocation, or suspension of any license, permit, or privilege to operate a motor vehicle?(Required) Yes No Please describe in detail the facts and circumstances of such denial, suspension or revocation 5. Applicant's Skills and QualificationsCheck those skills that you have. List any other skills that may be useful for the job you are seeking. Enter the number of years of experience, and circle the number which corresponds to your ability for each particular skill. (One represents poor ability, while five represents exceptional ability.)Please select from the following abilities or skills that apply: Mechanical Experience Customer Service Driving Experience CDL/Hazmat License Quickbooks Microsoft Office Other Skills/Experience (Please select all that apply.) Years of Mechanical Experience Years of Customer Service Experience Years of Driving Experience Years of CDL/Hazmat Experience Years of Quickbooks Experience Years of Microsoft Office Experience Other Skills/Experience 6. Applicant's Employment HistoryList jobs for past 3 years and if applying for a Commercial Driving position include the past 10 years for commercial driving experience: *Note: FMCSRs stands for Federal Motor Carrier Safety Regulations First EmployerEmployer Name Supervisor Name Supervisor PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Position/Job Duties Held Reason for Leaving Start Date MM slash DD slash YYYY Are you still working at this company? Yes No End Date MM slash DD slash YYYY Were you subject to the FMCSRs while employed by that employer? Yes No Second EmployerEmployer Name Supervisor Name Supervisor PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Position/Job Duties Held Reason for Leaving Start Date MM slash DD slash YYYY Are you still working at this company? Yes No End Date MM slash DD slash YYYY Were you subject to the FMCSRs while employed by that employer? Yes No Third EmployerEmployer Name Supervisor Name Supervisor PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Position/Job Duties Held Reason for Leaving Start Date MM slash DD slash YYYY Are you still working at this company? Yes No End Date MM slash DD slash YYYY Were you subject to FMCSRs while employed by that employer? Yes No Fourth EmployerEmployer Name Supervisor Name Supervisor PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Position/Job Duties Held Reason for Leaving Start Date MM slash DD slash YYYY Are you still working for this company? Yes No End Date MM slash DD slash YYYY Were you subject to FMCSRs while employed by this employer? Yes No 7. Applicant's Education and TrainingDid you graduate from High School?(Required) Yes No Did you receive your GED?(Required) Yes No High School/GED Name and Address Did you attend College/University?(Required) Yes No Did you receive a degree?(Required) Yes No Degree Field Other Training Awards, Honors, Special Achievements Military Service Yes No Branch Specialized Training 8. ReferencesName(Required) First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Name(Required) First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Name(Required) First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)9. CDL RequirementsApplicant list the states and license numbers of all licenses held for the past 3 years.State, License #, Expiration Date, Class A,B,C, and Endorsements.Select any and all equipment classes that have been operated by applicant Straight Truck Tractor Semi Trailer Tractor with Doubles Tractor with Triples Tractor with Tanks Straight Truck Dates Operated and Approximate Miles e.g. 12/8/15 - 1/26/21 10,000 milesTractor Semi Trailer Dates Operated and Approximate Miles e.g. 12/8/15 - 1/26/21 10,000 milesTractor with Doubles Dates Operated and Approximate Miles e.g. 12/8/15 - 1/26/21 10,000 milesTractor with Triples Dates Operated and Approximate Miles e.g. 12/8/15 - 1/26/21 10,000 milesTractor with Tanks Dates Operated and Approximate Miles e.g. 12/8/15 - 1/26/21 10,000 milesOther equipment classes that have been operated by applicant Dates Operated and Approximate Miles e.g. 12/8/15 - 1/26/21 10,000 milesAccidents/Crashes for the past 3 years or moreDate of Accident MM slash DD slash YYYY Nature of Accident (Backing, Head-on, Rollover, Turning) Fatalities Injuries Date of Accident MM slash DD slash YYYY Nature of Accident (Backing, Head-on, Rollover, Turning) Fatalities Injuries Date of Accident MM slash DD slash YYYY Nature of Accident (Backing, Head-on, Rollover, Turning) Fatalities Injuries Have you had any moving traffic convictions and/or forfeitures in the past 3 years? Yes No Please describeDate, Offense, Location, and Type of Vehicle UsedDriver Pre-Employment Verification of Testing ResultsThis company requires all Drivers who drive Commercial Motor Vehicles (CMV) which require a Commercial Drivers License (CDL), to be controlled substances tested with a negative result prior to driving. Do you consent to such Testing? Yes No In the past 2 years have you tested positive for any Controlled Substances pre-employment test for any other company? Yes No In the past 2 years have you tested above .04 on any Alcohol pre-employment test for any other company? Yes No In the past 2 years have you refused to be tested for any pre-employment test for any other company? Yes No If you answer “yes” to any of the above questions, provide the following information on the Substance Abuse Professional (SAP) you consulted.Name of SAP First Last SAP Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneDate Vistited MM slash DD slash YYYY I certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination. I understand that the information submitted on this application will be used for the purpose of investigating the applicant’s background, including contacting the applicant’s prior employers and obtaining the applicant’s driving record as well as driving performance history for the preceding three years for each DOT regulated employer as well as the state or appropriate agency for which a motor vehicle operator’s license is held. I authorize Powers Oil Ltd to contact former employers, the State and/or appropriate agency, as well as educational organizations regarding my employment, driving record, driving safety performance history and education. I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades. I authorize those persons designated as references to fully and freely communicate information regarding my previous employment and education. I understand that as a part of the Hazardous Materials Endorsement Threat Assessment Program, the TSA implemented on January 31, 2005 and Powers Oil Ltd. dba Powers Oil and Propane’s driver qualification policy a criminal background check will be conducted at the time of hire and as needed in the future to meet the company’s security plan and Hazardous Materials Endorsement compliance. I authorize Powers Oil Ltd. to conduct a criminal background check both now and in the future. If an employment relationship is created, I understand that unless I am offered a specific written contract of employment signed on behalf of the organization by its Owner, the employment relationship will be "at-will." In other words, the relationship will be entirely voluntary in nature, and either I or my employer will be able to terminate the employment relationship at any time and without cause. With appropriate notice, I will have the full and complete discretion to end the employment relationship when I choose and for reasons of my choice. Similarly, my employer will have the right. Moreover, no agent, representative, or employee of Powers Oil Ltd, except in a specific written contract of employment signed on behalf of the organization by its Owner, has the power to alter or vary the voluntary nature of the employment relationship. I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO ITS TERMS. THIS CERTIFIES THAT THIS APPLICATION WAS COMPLETED BY ME, AND THAT ALL ENTRIES ON IT AND INFORMATION IN IT ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. Name(Required) First Last Signature(Required) Reset signature Signature locked. Reset to sign again Date(Required) MM slash DD slash YYYY
