Mining & Environmental Services
Application for Employment


It is the policy of this company to provide equal employment opportunities to all qualified persons without regard to race, creed, color, religious belief, sex, age, national origin, physical or mental handicap or veteran status.

Personal Information


First Name:


Middle Initial:


Last Name:


Current Address:
Street and Apt #:


City:


State:


Zip Code:


Permanent Address (if different from above):
Street and Apt #:


City:


State:


Zip Code:


Additional Contact Information
Telephone:


Alternate Telephone:


E-mail Address:


Driver's License #:


Driver's License State:




Position Information


Position Applying For:


How did you hear about our firm?:


Would you be able to work shift work?: Yes     No

Would you be able to travel for the job?: Yes     No

When would you be able to start?:

Desired salary: $ per




Present or Most Recent Employer


Employer:


Address:


Your position:


Salary:


Duties:


Dates of Employment: to

Supervisor Name:


Supervisor Title:


Supervisor Phone:


May we contact?: Yes     No

Reason(s) for leaving:





Prior Employer


Employer:


Address:


Your position:


Salary:


Duties:


Dates of Employment: to

Supervisor Name:


Supervisor Title:


Supervisor Phone:


May we contact?: Yes     No

Reason(s) for leaving:





Prior Employer


Employer:


Address:


Your position:


Salary:


Duties:


Dates of Employment: to

Supervisor Name:


Supervisor Title:


Supervisor Phone:


May we contact?: Yes     No

Reason(s) for leaving:





Prior Employer


Employer:


Address:


Your position:


Salary:


Duties:


Dates of Employment: to

Supervisor Name:


Supervisor Title:


Supervisor Phone:


May we contact?: Yes     No

Reason(s) for leaving:





Prior Employer


Employer:


Address:


Your position:


Salary:


Duties:


Dates of Employment: to

Supervisor Name:


Supervisor Title:


Supervisor Phone:


May we contact?: Yes     No

Reason(s) for leaving:





Prior Employer


Employer:


Address:


Your position:


Salary:


Duties:


Dates of Employment: to

Supervisor Name:


Supervisor Title:


Supervisor Phone:


May we contact?: Yes     No

Reason(s) for leaving:





Education


High School
High School Name and Address:


Did you Graduate?:
Yes     No

If you did not graduate, did you receive your GED?:
Yes     No     Not Applicable

Special honors or awards:




Technical or Vocational School
School Name and Address:


Did you Graduate?:
Yes     No

Degree or Certification:


Specialty:


Special honors or awards:




College or University
School Name and Address:


Did you Graduate?:
Yes     No

Degree:


Major:


Special honors or awards:




College or University
School Name and Address:


Did you Graduate?:
Yes     No

Degree:


Major:


Special honors or awards:



Other Education:





Skills


Please describe any experience, training or certifications you have in the following areas.

Mining Work:


Heavy Equipment Operations:


Equipment Maintenance and Repair:


Electrical Work:


Blasting or Explosives Work:


Welding and Fabrication:


Surveying:


Construction, Excavation, etc.:


Computer Skills:


Other skills, licenses or training you want us to know about:





Military Service


Have you ever served in the U.S. Military?: Yes     No

If yes, please provide the following information:

Branch of Service:


Rank at time of separation:


Served from: to

Military Occupation:





Languages


Languages other than English - Indicate competence level from 1 (low) to 5 (native fluency).

Language 1:    Read?    Write?    Speak?

Language 2:    Read?    Write?    Speak?



Mining


Do you have one or more years of underground mining experience?: Yes     No

If no, have you completed a new miner MSHA training course?: Yes     No



Eligibility to Work in the U.S.


Are you a U.S. Citizen or otherwise authorized to work in the United States on an unrestricted basis?:
Yes     No



Eligibility to Work with Explosives


E-1. Are you a fugitive from justice?:
Yes     No

E-2. Are you an unlawful user of, or addicted to, marijuana or any depressant, stimulant or narcotic drug, or any other controlled substance?:
Yes     No

E-3. Have you ever been convicted in any court of a felony, or any other crime, for which the judge could have imprisoned you for more than one year, even if you received a shorter sentence, including probation?:
Yes     No

E-4. Are you under indictment or information in any court for a felony, or any crime, for which the judge could imprison you for more than one year?:
Yes     No

E-5. Have you ever been adjudicated mentally defective (which includes having been adjudicated incompetent to manage your own affairs) or have you ever been committed to a mental institution?:
Yes     No

E-6. Have you ever been discharged from the Armed Forces under dishonorable conditions?:
Yes     No

E-7. Have you ever renounced your United States citizenship?:
Yes     No

E-8. Are you an alien in the United States, other than a lawful permanent resident?:
Yes     No

If you answered yes to any of questions E-1 through E-8, have you applied for and received restoration of explosives privileges?:
Yes     No     Not Applicable




Certification


I hereby certify that my answers and assertions set forth in this application and any other information submitted to Mining & Environmental Services LLC are true and complete to the best of my knowledge. If I am employed, I understand that any false statements on this application shall be considered sufficient cause for my dismissal. I hereby authorize this company to investigate any aspect of my prior educational and employment history.

Furthermore I understand that if I am hired, employment with this company is "at will," which means that either the company or I can terminate my employment for any reason not prohibited by state or federal law.

I agree
I do not agree

Date:





(The following ensures that a person, not an automated program, is making this request)

Enter the sum of one + zero: