Holcombe Energy Resource, LLC

27 Aldovin Rd, Tunkhannock, PA 18657
Office: (570) 836 – 8050 | Fax: (570) 836 – 6549 | Website: https://www.holcombeenergy.com

INSTRUCTIONS: Thank you for your interest in employment with Holcombe Energy Resource, LLC. To be considered for employment, please ensure that all portions of this employment application are accurate and complete. Should you require any accommodation during the application process, please contact management.

Please do not make reference to a resume. Attaching a resume does not satisfy any required fields of this application.

Holcombe Energy Resource, LLC is an equal opportunity company... It is understood that the information in this application will be used and that present and prior employers will be contacted for purposes of investigation as required by 391.23 of the 49 CFR Federal Motor Carrier Safety Regulations.

Applicant Signature (Type Name):

Date:

Personal Information

First Name

Middle Initial

Last Name

Email Address

Have you ever used any other names? (If "Yes", please explain for background/criminal check)

Mailing Address

City

State

Zip

Date of Birth (mm/dd/yy)

Home Phone

Mobile Phone

Can you, upon employment, submit verification of your legal right to work in the US? Yes No (Note: If offered employment, you will be required to submit documentation required by the IRCA)

State of Issuance

Expiration

Medical Cert Expiration

Associate Number (Employer Only)

Desired Employment

Desired Position

First Available Start Date

Compensation Desired

Have you worked for Holcombe Energy Resource before? If Yes, reason for leaving?

Have you previously applied here? If Yes, list last application date.

Did someone refer you to us? If Yes, who? (newspaper ad, current employee, walk-in, etc.)

Have you ever been bonded? If Yes, for what company and why?

Are you able to work “Night Shift”, if asked or assigned? If No, please explain.

Apart from religious observances, are you able to work all other times? Yes No

Education

School Level

Name of School

Graduated? (Y/N)

Degree / Certification Received

High School

College

Trade School / Other

Military Status

Have you served in the Military? Yes No

From:

To:

Rank at Discharge / Duties:

Reserve Status:

Employment Record

Please account for the last ten years of employment by answering all questions for each employer.

Employer 1 (Present or Last Employer)

Name of Employer

Employer's Phone

Address

City

State

Zip

Starting Date

Date Last Worked

Position Held

Rate of Pay

Supervisor Name

Supervisor Title

While employed, were you subject to the Federal Motor Carrier Safety Regulations? Yes No

Were you subject to Alcohol & Controlled Substances testing as required by DOT agency (49 CFR Part 40)? Yes No

Were you terminated or asked to resign? If "Yes", explain; If "No", print reason for leaving.

Summarize Type of Work Performed and/or Job Responsibilities:

Employer 2

Name of Employer

Employer's Phone

Address

City

State

Zip

Starting Date

Date Last Worked

Position Held

Rate of Pay

Supervisor Name

Supervisor Title

While employed, were you subject to the Federal Motor Carrier Safety Regulations? Yes No

Were you subject to Alcohol & Controlled Substances testing? Yes No

Were you terminated or asked to resign? Reason for leaving:

Summarize Type of Work Performed:

Employer 3

Name of Employer

Employer's Phone

Address

City

State

Zip

Starting Date

Date Last Worked

Position Held

Rate of Pay

Supervisor Name

Supervisor Title

While employed, were you subject to the Federal Motor Carrier Safety Regulations? Yes No

Were you subject to Alcohol & Controlled Substances testing? Yes No

Were you terminated or asked to resign? Reason for leaving:

Summarize Type of Work Performed:

Employer 4

Name of Employer

Employer's Phone

Address

City

State

Zip

Starting Date

Date Last Worked

Position Held

Rate of Pay

Supervisor Name

Supervisor Title

While employed, were you subject to the Federal Motor Carrier Safety Regulations? Yes No

Were you subject to Alcohol & Controlled Substances testing? Yes No

Were you terminated or asked to resign? Reason for leaving:

Summarize Type of Work Performed:

CDL Information

List all drivers licenses held in past five (5) years (operator and chauffeur): list current first

State

License Number

Type

Expiration Date

List all traffic convictions and forfeitures for past five (5) years: truck and car other than parking

Date

Location (State)

Charge

Penalty

List all accident involvement Personal and Professional with truck and car for past five (5) years:

Date

Type of Vehicle Driven

Type of Accident

Preventable (Y/N)

Injury / Damage

Last:

Driving Experience:

Class of Equipment

Type of Trailer (van, tank, etc.)

From Date

To Date

Approx Miles

List any safe driving awards earned:

List any other driver training you have received:

Character References

Someone who can verify background & employment dates other than relatives or former employers.

Name

Occupation

Phone

Number of Years Known

General

Have you ever been denied a license, permit or privilege to operate a motor vehicle? If "Yes", please explain.

Has any license or privilege even been suspended or revoked? If "Yes", please explain.

Have you ever been disqualified to any section of Federal Motor Carrier Safety Regulations? If "Yes", please explain.

Have you ever been suspended, discharged, or released from any job? If "Yes", please explain.

Have you ever been convicted of any misdemeanor or felony? If "Yes", please explain.

Have you been licensed in other states or provinces? If "Yes", please explain.

Certification Statement

It is understood that the applicant, by presenting the application for employment, represents that the statements given by the applicant for the information requested in the application are true, correct, and complete, and that any false, misleading, or incomplete statement of information requested in this application shall be considered acts of dishonesty and be sufficient grounds for cancellation of the contract or termination of employment.

I understand and acknowledge, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature... I authorize investigation of all statements contained in this application, personal history, financial, credit record, and criminal history as may be necessary in arriving at an employment decision.

In connection with my application with the Holcombe Energy Resource, LLC; I understand that an investigative consumer report is being requested from third party information providers... I authorize, without reservation, any party or agency contracted by Employer, or other third party information services, to furnish the above mentioned information. I also understand and agree to subsequent driving record & criminal checks in the event I am hired.

I understand by written request I have the right to review information provided by my previous employers... I understand I have the right to request the nature and substance of all consumer reports on me at the time of my request.

"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."

Applicant Signature (Type Name):

Date:

Drug & Alcohol Test Results / Treatment Records & Refusal to Test History

Fair Credit Reporting Act Authorization

By signing below, you grant Holcombe Energy Resource, LLC authorization to obtain reports of the following nature, specifically: Motor Vehicle Record, Drug & Alcohol Test Results, Verifying Previous Employment.

A Summary of Your Rights Under the Fair Credit Reporting Act

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies... You must be told if information in your file has been used against you. You have the right to know what is in your file. You have the right to dispute incomplete or inaccurate information. Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Consumer reporting agencies may not report outdated negative information. Access to your file is limited. You must give your consent for reports to be provided to employers.

In accordance with the provisions of Section 604(b)(2)(A) of the Fair Credit Reporting Act... you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. These reports are required by Sections 382.413, 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations.

Applicant Signature (Type Name):

Date:

Employment Application

Holcombe Energy Resource, LLC

Personal Information

Desired Employment

Education

Military Status

Employment Record

Employer 1 (Present or Last Employer)

Employer 2

Employer 3

Employer 4

CDL Information

List all drivers licenses held in past five (5) years (operator and chauffeur): *list current first*

List all traffic convictions and forfeitures for past five (5) years: *truck and car other than parking*

List all accident involvement Personal and Professional with truck and car for past five (5) years:

Driving Experience:

Character References

General

Certification Statement

Drug & Alcohol Test Results / Treatment Records & Refusal to Test History

Fair Credit Reporting Act Authorization

List all drivers licenses held in past five (5) years (operator and chauffeur): list current first

List all traffic convictions and forfeitures for past five (5) years: truck and car other than parking