Application for Employment Step 1 of 3 33% We are an Equal Opportunity Employer and committed to excellence through diversity. The application must be fully completed to be considered. Please complete each section, even if you attach a resume.Personal InformationName(Required) Social Security #(Required) Address(Required) 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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone(Required)Email(Required) Are you legally eligible to work in the US?(Required) Yes No Are you a veteran?(Required) Yes No If selected for employment are you willing to submit to a background check?(Required) Yes No Date of Birth(Required) MM slash DD slash YYYY PositionPosition you are applying for(Required) Available start date(Required) MM slash DD slash YYYY Desired pay(Required) Employment desired(Required) Full time Part time Seasonal/Temporary EducationEnter High School / University Information(Required)School NameLocationYears AttendedDegree receivedMajor Add RemoveClick on the "+" to add another school.References(Enter business and professional references only.)(Required)NameTitleCompanyPhone Add RemoveClick on the "+" to add another reference.Employment History(Enter business and professional references only.)(Required)EmployerJob TitleDates EmployedWork PhoneStarting Pay RateEnding Pay RateAddress Add RemoveClick on the "+" to add another employer.Signature DisclaimerI certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my employment being terminated.Name(Required) Date(Required) MM slash DD slash YYYY Signature(Required) Authorization to Obtain Motor Vehicle RecordTHE UNDERSIGNED DOES HEREBY ACKNOWLEDGE AND CERTIY AS FOLLIOWS: Certifies that the undersigned is an employee, or has applied to become an employee of the below names employer in a position which involves the operation of a motor vehicle and the undersigned gives his or her consent to the release of their driving record (MVR) for review by:Name of Employer or Potential Employer That the undersigned authorizes his or her driving record to be periodically obtained and reviewed for the purpose of initial and continued employment. That all information presented in this form is true and correct. The undersigned makes this certification and affirmation under penalty of perjury and understands that knowingly making a false statement or representation on this form is a criminal violation.Name of Employee/Potential Employee Print name as it appears on driver's licenseLicense Number & State Date of Birth MM slash DD slash YYYY Signature of Employee/Potential EmployeeDate MM slash DD slash YYYY CONDITIONAL OFFER OF EMPLOYMENT SUBJECT TO JOB DUTY CONFIRMATION QUESTIONNAIRE Notice: You have received a conditional offer of employment. In compliance with the Americans with Disabilities Act, this job duty confirmation questionnaire is required of all individuals who received offers for the job for which you applied. Your answers to this questionnaire will be kept confidential and separate from your personnel file. The job offer that you have received is conditioned upon your ability to perform the job duties of the position. Consistent with the ADA and other applicable federal and state laws, it is the policy of Rogue to provide reasonable accommodation when requested by a qualified applicant or employee with a disability, unless such accommodation would cause an undue hardship. The policy regarding requests for reasonable accommodation applies to all aspects of employment, including the application and hiring process. If reasonable accommodation is needed to perform any of the tasks set forth below, whether now or later in your employment, please contact David Hooper at 325-650-2320. The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not collect or provide any genetic information when responding to the questions set forth in this form. “Genetic information,” as defined by GINA, includes an individual's family medical history, the results of an individual's or family member's genetic tests, the fact that an individual or an individual's family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services. Dear [New Hire}, We are pleased that you have chosen to accept the position of (full time/part time) Position Applying For with Rogue Energy Services, LLC’s conditional offer of employment and look forward to your first day of work. We believe you will find working at Rogue a rewarding experience. As part of your employment with Rogue, you will be provided with an employee handbook, Rogue policies, and training. After sixty (60) days, you will be eligible to receive all normal and customary benefits offered to regular [full time/part time] employees as outlined in the employee handbook. You will still be considered an at-will employee. Your employment with Rogue is contingent on your ability to perform all job functions, duties, and responsibilities associated with the position with or without reasonable accommodations. Prior to completing your job application, Rogue provided you with a job description. In order to determine whether you can fulfill these responsibilities, Rogue requests that you answer the following questions. Rogue will notify you once it has reviewed your responses. Name First Middle Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Please answer the following:1. Are you able to perform all of the work stated in the job description and skills and qualificationsfor the position for which you were given a conditional offer of employment? Yes No 2. Are you able to carry objects that weigh up to fifty (50) pounds throughout the workday? Yes No 3. Are you able to work from heights that will require using fall protection equipment? Yes No 4. Are you able to work outdoors in temperatures over ninety (90) degrees? Yes No 5. Are you able to work outdoors in temperatures under forty (40) degrees? Yes No 6. Are you able to work twelve (12) hours on a single work-shift? Yes No 7. Are you able to work in cramped spaces? Yes No 8. Are you able to use a full-face oxygen mask? Yes No The above statements are true and to the best of my knowledge.SignatureName Date MM slash DD slash YYYY Δ
