Chemoil Application Form – Fill Out and Use This PDF

4 East Sheridan, Suite 400

Oklahoma City, OK 73104

Driver Application for Employment:

*This Application must be filled out completely, in Blue or Black ink and in your own handwriting. If an item does not apply to you, please write N/A. Before you complete the application know the information your provide in accordance with 391.21 Part (b)(1-10) shall be used and your previous employers contacted for the purposes of investigating your Safety Performance History as required in 391.23 (d) & (e).

Appli a t’s Na e:

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

(Last Name)(First Name) (Middle Initial) (Date of Application)

Current Address:

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

(Current Street Address)

(City)

(State)

(Zip Code)

*If at the above address less than three (3) years, list below all residences for the past three years. Attach a separate sheet if necessary.

Previous Addresses:

_____________________________________________________________________________________

(Street Address)	(City)	(State)	(Zip Code)	(How long? Yrs./Mo.)
_____________________________________________________________________________________
(Street Address)	(City)	(State)	(Zip Code)	(How long? Yrs./Mo.)
_____________________________________________________________________________________
(Street Address)	(City)	(State)	(Zip Code)	(How long? Yrs./Mo.)
_____________________________________________________________________________________
(Street Address)	(City)	(State)	(Zip Code)	(How long? Yrs./Mo.)

Home Phone: ( )_________________________		Cell Phone: (		) __________________________
Email Address: ____________________________		Fax Number: (		) _________________________
Date of Birth: _____________________________		Social Security Number: ____________________
		Desired Position:
Position Applying For:	_____________________	State:	________________________________
	(Transport or Frac Refill)		(City & State of Operation)
What shifts are you		Salary
able to work:	_____________________	Desired:	________________________________

					4 East Sheridan, Suite 400
					Oklahoma City, OK 73104
		Commercial Motor Vehicle Experience:
Class of Equipment:		Years of Operation:	Approximate Miles:		Type of Equipment:
					Va , Flat ed, Ta k ago , et …
Tanker (80,000 GVWR):
Straight Truck:
T i T aile s LCV’s :
Other:

		Dri er’s Li e se I	for atio :
D i e ’s Li e se Nu e :	________________	Issuing State:	_________________ License Class (A/B):		____________
Endorsements:	________________	CDL Issue Date:	_________________	CDL Expiration Date:	____________
Do you have any		If yes,
restrictions on your	______________	please explain:	________________________________________________
license?

Has your license, or permit to drive or privilege to operate a motor vehicle ever been denied, revoked, or suspended? If yes, please provide a statement detailing the facts and circumstances _______________________________________

__________________________________________________________________________________________________

Accident History: (Please provide accidents for the last three (3) years. Attach additional page(s) if necessary.)

Date of Incident:	Type of Accident:	Number of Fatalities	Number of Injuries		Hazardous Materials
	(Head-on, Rear-e d, Rollo er, et …						Spill?
						YES			NO
						YES			NO
						YES			NO

4 East Sheridan, Suite 400

Oklahoma City, OK 73104

Work History: (List current or most recent employer first, then all previous employers for the last 10 years. Account for all periods of unemployment or self-employment. (Your application will not be processed without 10 years work history.)

Current or Last Employer Name: _________________________________________________________________

__________________________________________________________________________________________________

(Address)

(City)

(State & Zip Code)

Job Title:

_____________________ Supervisor Name:

________________________________________________

Reason for Leaving:

________________________________________________________________________________

Major Job Duties:

________________________________________________________________________________

Dates of Service – From:

_________________________

To:

__________________

Wages: ______________

Was this position subject to FMCSR Rules?

Yes or No

Was this a Safety Sensitive Position?

Yes

or

No

Phone Number:

(

)_________________________

Contact Name:

_______________________________

Previous Employer Name:

_________________________________________________________________

__________________________________________________________________________________________________

(Address)

(City)

(State & Zip Code)

Job Title:

_____________________ Supervisor Name:

________________________________________________

Reason for Leaving:

________________________________________________________________________________

Major Job Duties:

________________________________________________________________________________

Dates of Service – From:

_________________________

To:

__________________

Wages: ______________

Was this position subject to FMCSR Rules?

Yes or No

Was this a Safety Sensitive Position?

Yes

or

No

Phone Number:

(

)_________________________

Contact Name:

_______________________________

	4 East Sheridan, Suite 400
	Oklahoma City, OK 73104
Previous Employer Name:	_________________________________________________________________

__________________________________________________________________________________________________

(Address)

(City)

(State & Zip Code)

Job Title:

_____________________ Supervisor Name:

________________________________________________

Reason for Leaving:

________________________________________________________________________________

Major Job Duties:

________________________________________________________________________________

Dates of Service – From:

_________________________

To:

__________________

Wages: ______________

Was this position subject to FMCSR Rules?

Yes or No

Was this a Safety Sensitive Position?

Yes

or

No

Phone Number:

(

)_________________________

Contact Name:

_______________________________

Previous Employer Name:

_________________________________________________________________

__________________________________________________________________________________________________

(Address)

(City)

(State & Zip Code)

Job Title:

_____________________ Supervisor Name:

________________________________________________

Reason for Leaving:

________________________________________________________________________________

Major Job Duties:

________________________________________________________________________________

Dates of Service – From:

_________________________

To:

__________________

Wages: ______________

Was this position subject to FMCSR Rules?

Yes or No

Was this a Safety Sensitive Position?

Yes

or

No

Phone Number:

(

)_________________________

Contact Name:

_______________________________

4 East Sheridan, Suite 400

Oklahoma City, OK 73104

Previous Employer Name:_________________________________________________________________

__________________________________________________________________________________________________

(Address)

(City)

(State & Zip Code)

Job Title:

_____________________ Supervisor Name:

________________________________________________

Reason for Leaving:

________________________________________________________________________________

Major Job Duties:

________________________________________________________________________________

Dates of Service – From:

_________________________

To:

__________________

Wages: ______________

Was this position subject to FMCSR Rules?

Yes or No

Was this a Safety Sensitive Position?

Yes

or

No

Phone Number:

(

)_________________________

Contact Name:

_______________________________

Motor Vehicle Record Release:

I hereby authorize you to release my Motor Vehicle Record (MVR) to Chemoil Energy pursuant to the Federal Motor
Carrier Safety Regulations, parts 39123 (a)(1) and 391.25(a)(b)(1) and (2). You are released from any and all liability
which may result from furnishing such information. I further understand this info	atio	ill	e used fo pe	issi	le
pu pose a d ill ot e dis losed o t a sfe ed to othe pa ties ot affiliated	ith Che	oil E	e g . This is a	o su	e

report and the information obtained will not be used in violation of any federal, state, or equal opportunity law or regulation. Upon receipt and review of the report; and before taking any adverse action based in whole or in part of the report; Chemoil Energy will provide the applicant a copy of the report and the summary of consumer rights as provided with the report by the consumer reporting agency.

Applicant Signature: X __________________________ Date:

X________________________________________

4 East Sheridan, Suite 400

Oklahoma City, OK 73104

FMCSA Pre-Employment Screening (PSP) Release:

1. I o e tio ith ou appli atio fo e plo e t ith Che oil E e g P ospe ti e E plo e , it a o tai o e o

more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).

When the application for employment is submitted in person, if the Prospective Employer uses and information it obtains from FMCCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report.

When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three (3) business days of taking adverse action oral, written, or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address and toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of a driver record from the Prospective Employer who procured the report, then, within three (3) business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act.

The Prospective Employer cannot obtain background reports from FMCSA unless you consent in writing.

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

2. I authorize Chemoil E e g P ospe ti e E plo e to a ess the FMC“A P e-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am consenting to the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee.

3.I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov . If I am challenging crash or inspection

information reported by a State, FMCSA cannot change or correct the data. I understand my request will be forwarded by

the DataQ’s s ste to the app op iate age

fo adjudi atio .

4.Please Note: Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.

I have read the above Notice Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this consent form, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.

Dri	er’s Na	e Pri	ted : _____________________________________________________________________________
Dri	er’s Sig	ature:	_______________________________________ Date: ____________________________

4 East Sheridan, Suite 400

Oklahoma City, OK 73104

Previous Employer Request for Employment Verification and Safety Performance History

I, ______________, hereby authorize Chemoil Energy to obtain the following information for the purposes stated in

(Print Name)

49 CFR 391.23 and release all previous employers from any liability resulting from providing such information. Employment verification and safety performance history are required.

Applicant Signature: X __________________________ Date:

X________________________________________

The above-named applicant has applied for a driving position with Chemoil Energy. Would you please provide the following

information, as required, and fax back to us at (405)605-5499?

Applicant Name:	X __________________________ Birth-Date: X___________________________________
	Previous Employer Questions:
Did your company employ this applicant?				YES			NO
If yes, what dates was the applicant employed?		From:_____________________			To:__________________________

What type of work was performed? _____________________________________________________________________

What type of motor vehicle did the applicant drive on		Straight Truck		Trailer-Semitrailer					Bus
behalf of your company?		Cargo Tanker		Doubles/Triples					Other
Was the applicant a safe and efficient driver?		YES				NO
Was the appli a t’s ge e al o du t satisfa to ?		YES				NO
Reason for leaving your Company?		Discharge		Resignation				Lay-Off

Previous Employer Accident History:

Please complete the following information for any accidents included on your accident register (49 CFR 390.15(b)) that

involved the applicant in the three (3) years prior to the applicant date shown above, or check here if there is no accident register data for this Driver.

4 East Sheridan, Suite 400

Oklahoma City, OK 73104

Accident Record: (Please provide for last three (3) years. Attach additional pages if necessary)

Date of Accident:	Type of Accident:	Number of Fatalities:	Number of Injuries:	Hazardous Materials Spill:
	(Head-On, Rear-E d, Rollo er, et …
						YES		NO
						YES		NO
						YES		NO
						YES		NO
						YES		NO

Please list additional accident information on a separate page as well as information on accidents you may wish to provide pursuant to 390.15(b)(2) or your internal company policies.

(1)	Employer:	______________________	Location:
Fax Number:		______________________	Date/Time Faxed:
(2)	Employer:	______________________	Location:
Fax Number:		______________________	Date/Time Faxed:
(3)	Employer:	______________________	Location:
Fax Number:		______________________	Date/Time Faxed:

4 East Sheridan, Suite 400

Oklahoma City, OK 73104

Previous Employer Request for Drug & Alcohol Testing Results

In compliance with the Department of Transportation (DOT), Federal Motor Carrier Safety Regulations, the information received and contained will remain confidential and in accordance with 49 CFR 40.25(g). Under Parts 49 CFR 40.25, 382.405(f)(h) and 391.23(e) requires this information be collected from all previous employers for whom you worked for in the last three years in a DOT safety sensitive position that required pre-employment and random drug and alcohol screening.

I, _______________________ hereby release my drug and alcohol records for the last three years from the employers listed below;

(Print Name)

from the date I signed this form, to Chemoil Energy located at 4 East Sheridan, Suite 400, Oklahoma City, OK 73104 in compliance

ith the Depa t e t of T a spo tatio , Fede al Moto Ca ie ’s “afet Regulatio s.

Applicant Signature: X __________________________

Date:

X________________________________________

Previous Employer Drug and Alcohol History

Was this driver subject to Department of Transportation testing requirements while employed by your

YES

NO

company?

What period of time was the driver subject to DOT testing?

From: ________________ To: ____________________

Please respond to the following questions if the driver was subject to Department of Transportation testing – Has this Person:

Had an alcohol test with the result of 0.04 or higher alcohol concentration?

YES

NO

Tested positive or adulterated or substituted a test specimen for controlled substances?

YES

NO

Refused to submit to a post-accident, random, reasonable suspicion, or follow-up alcohol or controlled

YES

NO

substance test?

Committed other violations of Subpart B of Part 382, or Part 40?

YES

NO

If this person has violated a DOT drug and alcohol regulation, did this person complete a SAP-

YES

NO

prescribed rehabilitation program during the employment period, including return-to-day and

Not Applicable

follow-up tests?

If this pe so o pleted a “AP’s

eha ilitatio efe al a d e ai

ed e plo ed at ou

YES

NO

Company, did he/she subsequently have an alcohol test result of 0.04 or greater, a verified

Not Applicable

positive drug test, or refuse to be tested?

Person Supplying Information:

_________________________

Title:

_________________________

Company:

_________________________

Telephone:

_________________________

Signature:

_________________________

Date:

_________________________

Please list all DOT regulated employers you have worked for in a safety-sensitive function during the previous three (3) years. If

necessary attach an additional page, including the previous employer, city, state, and phone number.
Previous DOT Regulated Employer	City	State		Phone Number
__________________________	___________________	__________________________	(	)__________________
__________________________	___________________	__________________________	(	)__________________
__________________________	___________________	__________________________	(	)__________________
__________________________	___________________	__________________________	(	)__________________
__________________________	___________________	__________________________	(	)__________________
By signing below, I certify that: (1) All information provided herein is complete and accurate; and (2) I execute this authorization
voluntarily with the knowledge that the information obtained pursuant to this authorization could affect my eligibility for
employment.

Applicant Signature: X ______________

Applicant Name (Print): X _______________ Date:

X____________

4 East Sheridan, Suite 400

Oklahoma City, OK 73104

Previous Pre-Employment Employee Alcohol & Drug Testing Statement

Sec. 40.25(j) requires Chemoil Energy to ask the employee whether he or she has tested positive, or refused to test, on any pre- employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety- sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two (2) years. If the employee admits that he or she had a positive test or a refusal to test, you must not use the employee to perform safety-sensitive functions for you, until and unless the employee documents successful completion of the return-to-duty process (see Sec. 40.25 (b) (5) and (e)).

D i e ’s Na e Fi st, MI, Last :	_________________________________________________________________________________
Social Security Number:	_________________________________________________________________________________

The prospective employee is required by Sec. 40.25(j) to respond to the following questions:

1.Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two (2) years?

		YES			NO
2. If ou a s			e ed es, a ou p o ide/o tai p oof that ou’ e su essfull o pleted the DOT etu -
to-duty requirements?
		YES			NO

I certify that the information provided on this document is true and correct.

Dri er’s Signature:	X __________________________	Date:	X________________________________________
Company
Representative:	X __________________________	Date:	X________________________________________

4 East Sheridan, Suite 400

Oklahoma City, OK 73104

Certification of Compliance with Driver License Requirements

Motor Carrier Instructions:

The requirements in Part 383 apply to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle weighing 26,001 pounds or more, can transport more than fifteen (15) people, or transports hazardous materials that require placarding.

The requirements in Part 391 apply to every driver who operates in interstate commerce and operates a vehicle weighing 10,001 pounds or more, can transport more than fifteen (15) people, or transports hazardous materials that require placarding.

Driver Requirements:

Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain certain driver license requirements that you as a driver must comply with, including the following:

1.POSSESS ONLY ONE LICENSE: You, as a commercial vehicle driver, may not possess more than one

oto ehi le ope ato ’s li e se.

2.NOTIFICATION OF LICENSE SUSPENSION, REVOCATION, AND/OR CANCELLATION: Sec. 391.15(b)

(2) and 383.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of a e o atio o suspe sio of ou d i e ’s li e se. I addition, Sec. 383.31 requires that any time you are convicted of violating a state or local traffic law (other than parking), you must report it within 30 days to: 1) your employing motor carrier,

and 2) the state that issued your license (if the violation occurs in a state other than the one which

issued your license). The notification to both the employer and state must be in writing.

3. CDL DOMICILE REQUIREMENT: “e . . a e ui es that ou o e ial d i e ’s li e se e issued by your legal state of domicile, where you have your true, fixed, and permanent home and principal residence and to which you have the intention of returning whenever you are absent. If you establish a new domicile in another state, you must apply to transfer your CDL within 30 days.

The following License is the only one I possess:

Driver License Number: _ ______________ State:

__ _______________ Expiration Date: ______________

DRIVER CERTIFICATION: I certify that I have read and understand the above requirements.

D i e ’s Na e P i	ted :	_________________________________________________________________________________
D i e ’s “ig	atu e:	_______________________________________	Date: ______________________________
Notes:		_________________________________________________________________________________

4 East Sheridan, Suite 400

Oklahoma City, OK 73104

Commercial Driver License Self-Certification

D i e ’s Na e Fi st, MI, Last :	_________________________________________________________________________________
D i e ’s Li e se Nu e :	_________________________________________________________________________________

Effective January 31st, 2012, the Federal Motor Carrier Safety Administration (FMCSA) requires that all Commercial Driver License holders (CDL) self-certify to the motor carrier what type of operation they will perform. This self-certification is required and found in Part 391.71(a)(1)(ii) and 383.71(g). The Department of Transportation, (DOT and FMCSA) require that all licensed CDL holders obtain a copy of their medical examiners certificate when they are renewing their CDL. Additional documentation for CDL renewal is also required and that information can be found in Part 383.71(d).

I certify my commercial transportation is (please check only one (1) box):
		1.	Non-Excepted Interstate (NI): I certify that I operate or expect to operate in interstate commerce, is
			both subject to and meets the qualification requirements under 49CFR Part 391, and is required to
			o tai a	edi al e a	i e ’s e tifi ate		CFR	. .
		2.	Excepted Interstate (EI): I certify that I operate or expect to operate in interstate commerce, but engage
			exclusively in transportation or operations excepted under 49 CFR 390.3(f), 391.2, 391.68, or 398.3 from
			all or parts of the qualification requirements of 49 CFR Part 391, and is therefore not required to obtain a
			edi al e	a i e ’s	e tifi ate	CFR	. .

3. Non-Excepted Intrastate (NA): I certify that I operate only in intrastate commerce and therefore am subject to State driver qualification requirements.

4. Excepted Intrastate (EA): I certify that I operate in intrastate commerce, but engage exclusively in transportation or operations excepted from all or parts of the State driver qualification requirements.

Dri er’s Signature: X __________________________ Date: X________________________________________

4 East Sheridan, Suite 400

Oklahoma City, OK 73104

Hours of On-Duty Statement

INSTRUCTIONS: Motor carriers when using a driver for the first time shall obtain, from the Driver, a signed statement giving the total time on-duty during the immediately preceding seven (7) days and time at which such Driver was last relieved from duty prior to beginning work for such Carrier. (Reference Rule 395.8(j)(2) Federal Motor Carrier Safety Regulations)

NOTE: Hours for any compensated work during the preceding seven (7) days, including work for a non-motor carrier entity, must be recorded on this form.

Driver Name (First, MI, Last):

________________________________________________________________________________

Social Security Number:

________________________________________________________________________________

D i e ’s Li e

se Nu e :

______________

State:

_________________

Class:

__________________________

Endorsements:

________________________________________________________________________________

Day

1

2

3

4

5

6

7

Day Ago

Days Ago

Days Ago

Days Ago

Days Ago

Days Ago

Days Ago

Date

Total Hours

Hours Worked

I hereby certify that the information given above is correct to the best of my knowledge and belief, and that I was last relieved from work at:

___________________	AM		___________________ ___________________		___________________
Time	PM	ON:	Day	Month	Year
Dri er’s Signature:	X __________________________ Date:			X________________________________________

Driver Certification for other compensated work:

INSTRUCTIONS: When employed by a motor carrier, a driver must report to the carrier all on-duty time including time working for other employers. The definition of on-duty time found in Section 395.2, paragraphs (8) and (9) of the Federal Motor Carrier Safety Regulations includes time performing any other work in the capacity of, or in the employment or service of, a common, contract, or private motor carrier, also performing any compensated work for any non-motor carrier entity.

Are you currently working for another employer?		YES		NO
At this time, do you intend to work for another employer while still employed		YES		NO
by this Company?

I hereby certify that the information given above is true and I understand that once I become employed by Chemoil Energy, if I begin working for any additional employer(s) for compensation that I must inform Chemoil Energy immediately, in writing, or such intended employment activity.

Dri er’s Signature:	X __________________________	Date:	X________________________________________
Company
Representative:	X __________________________	Date:	X________________________________________