spinnaker oilfield services company llc · spinnaker oilfield services company llc employment...
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SPINNAKER OILFIELD SERVICES COMPANY LLC
3675 S ALFADALE RD, EL RENO, OK 73036 [email protected]
APPLICATION FOR EMPLOYEMENT
(DRIVER’S ADDENDUM)
YOU MUST ANSWER EVERY QUESTION. IF ANY QUESTIONS DO NOT APPLY TO YOU,
ANSWER WITH NOT APPLICABLE (NA). In compliance with local, state, and federal Equal Employment
Opportunity laws, qualified applicants are considered for all positions without regard to age, race, color, sex,
sexual orientation, marital status, veteran status, or non-job related disability. Please advise in advance if you need
any type of special accommodation(s) to complete this application form or need to take any pre-employment test.
DATE:_____/_____/_____ SOCIAL SECURITY NO. ___________________
NAME:__________________________________________________________________
(LAST) (FIRST) (MI)
ADDRESS:___________________________________________________________ HOW LONG:__________
(STREET) (CITY) (STATE/ZIP)
IF YOU WERE AT ABOVE ADDRESS LESS THAN THREE (3) YEARS, LIST YOUR PREVIOUS ADDRESS, USE
BACK SIDE OF THIS APPLICATION FOR ADDITIONAL ADDRESSES:
ADDRESS:_______________________________________________________________ HOW LONG:_______
(STREET) (CITY) (STATE/ZIP)
PHONE NUMBER:______________________ PHONE (CELL PREFERRED)________________
ARE YOU PREVENTED FROM BEING LAWFULLY EMPLOYED IN THE U.S. DUE TO YOUR VISA OR IMMIGRATION STATUS? (PLEASE
CHECK ONE) YES NO
HAVE YOU WORKED FOR THIS COMPANY BEFORE? YES NO IF SO, WHEN? ________________________
ARE YOU CURENTLY EMPLOYED? YES NO IF NO, HOW LONG SINCE LEAVING LAST EMPLOYEMENT? _____________
HAVE YOU EVER BEEN FIRED OR ASKED TO RESIGN BY AN EMPLOYER? YES NO
HAVE YOU EVER BEEN CONVICTED OF A MISDEMEANOR OR FELONY? YES NO (Answering this question in an affirmative answer
does not necessarily preclude a hiring decision.) IF YES, TO THE ABOVE QUESTION, PLEASE PROVIDE DETAILS:
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
WHO REFERRED YOU? ____________________________________________ RATE OF PAY EXPECTED? ____________________________
APPLICANT SIGNATURE _____________________________________________________________ DATE: ____________________________
I 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 release.
Spinnaker Oilfield Services Company LLC DRIVER’S DATA SHEET
DATE: ______________________
Personal Information
NAME:____________________________________________________________
ADDRESS:_________________________________________________________
_________________________________________________________
HOME PHONE:___________________________ CELL PHONE:____________________
DATE OF BIRTH:________________ SOCIAL SECURITY #_______________________
NEAREST RELATIVE :__________________________________________________
NEAREST RELATIVE PHONE#:__________________________________________
YOUR EMAIL ADDRESS ______________________________________________________
DRIVER’S LICENSE INFORMATION
DRIVER’S LICENSE #:_______________________ ISSUING STATE:________________
CLASS:___________ EXPIRATION DATE:_______________ HAZMAT YES NO
ENDORSEMENTS (CIRCLE ALL THAT APPLY): TANKER DOUBLES TRIPLES
HIRE DATE:____________________ JOB TITLE:_______________________________
PRINTED DRIVER NAME:_________________________________________________
SIGNATURE OF DRIVER:______________________________ DATE: _______________
Spinnaker Oilfield Services Company LLC EMPLOYMENT HISTORY
§391.21 (b)(10) A list of the names and addresses of the applicant’s employers during the 3 years preceding the date of the application is submitted together with the dates he/she was employed by, and his/her reason for leaving the employ of, each employer; (b)(11) For those drivers applying to operate a commercial motor vehicle as defined by Part 383 of this subchapter, a list of the names and addresses of the applicant’s employers during the 7 year period preceding the 3 years contained in paragraph (b)(10) of this section for which the applicant was an operator of a commercial motor vehicle, together with the dates of employment and the reasons for leaving such employment. (Attach another sheet if more space is needed).
A total of 10 years work history is required. All gaps in time must be shown. Current or most recent employer
Business Name Employment Dates Start Date: End Date:
Address Position: Salary:
City/State/Zip Were you ever employed in safety sensitive subject DOT drug and
alcohol testing? Yes No
Phone No. Were you subject to Federal Motor Carrier Safety Regulations?
Yes No
Name of Supervisor Reason for Leaving
Next previous employer
Business Name Employment Dates Start Date: End Date:
Address Position: Salary:
City/State/Zip Were you ever employed in safety sensitive subject DOT drug and
alcohol testing? Yes No
Phone No. Were you subject to Federal Motor Carrier Safety Regulations?
Yes No
Name of Supervisor Reason for Leaving
Next previous employer
Business Name Employment Dates Start Date: End Date:
Address Position: Salary:
City/State/Zip Were you ever employed in safety sensitive subject DOT drug and
alcohol testing? Yes No
Phone No. Were you subject to Federal Motor Carrier Safety Regulations?
Yes No
Name of Supervisor Reason for Leaving
Next previous employer
Business Name Employment Dates Start Date: End Date:
Address Position: Salary:
City/State/Zip Were you ever employed in safety sensitive subject DOT drug and
alcohol testing? Yes No
Phone No. Were you subject to Federal Motor Carrier Safety Regulations?
Yes No
Name of Supervisor Reason for Leaving
Spinnaker Oilfield Services Company LLC EMPLOYMENT HISTORY
§391.21 (b)(10) A list of the names and addresses of the applicant’s employers during the 3 years preceding the date of the application is submitted together with the dates he/she was employed by, and his/her reason for leaving the employ of, each employer; (b)(11) For those drivers applying to operate a commercial motor vehicle as defined by Part 383 of this subchapter, a list of the names and addresses of the applicant’s employers during the 7 year period preceding the 3 years contained in paragraph (b)(10) of this section for which the applicant was an operator of a commercial motor vehicle, together with the dates of employment and the reasons for leaving such employment. (Attach another sheet if more space is needed).
A total of 10 years work history is required. All gaps in time must be shown. Current or most recent employer
Business Name Employment Dates Start Date: End Date:
Address Position: Salary:
City/State/Zip Were you ever employed in safety sensitive subject DOT drug and
alcohol testing? Yes No
Phone No. Were you subject to Federal Motor Carrier Safety Regulations?
Yes No
Name of Supervisor Reason for Leaving
Next previous employer
Business Name Employment Dates Start Date: End Date:
Address Position: Salary:
City/State/Zip Were you ever employed in safety sensitive subject DOT drug and
alcohol testing? Yes No
Phone No. Were you subject to Federal Motor Carrier Safety Regulations?
Yes No
Name of Supervisor Reason for Leaving
Next previous employer
Business Name Employment Dates Start Date: End Date:
Address Position: Salary:
City/State/Zip Were you ever employed in safety sensitive subject DOT drug and
alcohol testing? Yes No
Phone No. Were you subject to Federal Motor Carrier Safety Regulations?
Yes No
Name of Supervisor Reason for Leaving
Next previous employer
Business Name Employment Dates Start Date: End Date:
Address Position: Salary:
City/State/Zip Were you ever employed in safety sensitive subject DOT drug and
alcohol testing? Yes No
Phone No. Were you subject to Federal Motor Carrier Safety Regulations?
Yes No
Name of Supervisor Reason for Leaving
Spinnaker Oilfield Services Company LLC DRIVING HISTORY
Fair Credit Reporting Act- Disclosure
To Be Completed By Driver
In accordance with the provisions of Section 604 (b) (2) (A) of the Fair Credit Reporting Act,
Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D,
Chapter I, of Public Law 104-208), You are being informed that reports verifying your previous
employment, previous drug and alcohol test results, and your driving record will be obtained for
employment purposes with this company.
These reports are required by sections 382.413, 391.23, 391.21 and 391.25 of the Federal
Motor Carrier Safety Regulations.
Driver’s Name: Last First MI Social Security Number
Driver’s Signature Date
VSR- DQF019 MAR, 05
Request for Driving Record
Driver Applicant’s Release
I authorize you to release the following information to for the purpose of investigation as required under Section 391.21 and 391.23 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability which may result from furnishing such information.
Driver Applicant’s Signature Date
Requestor’s Statement
1. As specified in Section 604 and Section 607 of the Fair Credit Reporting Act, Public Law #91-508, I hereby certify that the information you provide regarding the applicant’s driving record for the last 3 years will be used for the “permissible purposes” as defined in the Act, and that the information received will be used for no other purpose. 2. I further certify that if the applicant named below is denied employment based upon the information received, I will identify the source of the report in accordance with Section 615 (a) of the Fair Credit Reporting Act.
Requestor’s Signature Date
To Whom It May Concern: The below named individuals has made application to this company for a Driver position. As in accordance with
Section 391.21 and 391.23, FMCSR, please furnish the undersigned with the applicant’s driving record for the past 3 years.
Applicant’s Name Last First MI Date of Birth SSN DL# Address City State Zip Previous Address City State Zip
Requested By
Co: Address City State Zip Contact Name Title Signature
BACKGROUND CHECK AUTHORIZATION
FMCSA DRUG & ALCOHOL TESTING & SAFETY PERFORMANCE INFORMATION
Section I: To be completed by the employee. Please fill out one sheet for each employer that you have had for the last 3 years. Please return 2
Pages for each employer.
EMPLOYEE NAME: SSN:
This release is in accordance with DOT regulation 49 CFR Parts 40, 382 and 391. I hereby authorize release of FMCSA regulated safety performance records, as well as the following information concerning DOT drug and alcohol testing violations including pre-employment tests during the past three years: (1) alcohol tests with a result of 0.04 or higher alcohol concentration; (2) verified positive drug tests; (3) refusals to be tested; (4) other violations of DOT agency drug and alcohol testing regulations; (5) documentation, if any, of completion of the return-to-duty process following a rule violation; (6) information obtained from previous employers of a drug and alcohol rule violation.
Previous Employer Name Address Phone Number
To the requesting employer / individual, and its agent Hire Level:
New Employer Name Address Phone Number
Spinnaker Oilfield Services 3675 S Alfadale Road, El Reno Oklahoma 73036 (405) 534-9190
EMPLOYEE SIGNATURE: DATE:
Section II: To be completed by previous employer and email to [email protected], along with the general employment
verification information. Applicants do not fill out section 2.
Controlled Substances and Alcohol Testing Information
In the previous three years, in regards to DOT-regulated testing:
1. Did the employee have alcohol tests with a result of 0.04 or higher? No Yes
2. Did the employee have any verified positive drug tests?
No Yes
3. Did the employee refuse to be tested? No Yes
4. Did the employee have any other violations of DOT agency drug and alcohol testing regulations? No Yes 5. Did a previous employer report a drug and alcohol rule violation to you? If yes, please provide the previous employer’s report along with this form.
No Yes
6. If you answered “yes” to any of the above items, did the employee complete the return-to-duty process? If yes, please provide appropriate return-to-duty documentation (e.g., SAP report(s), follow-up testing record).
N/A No Yes
7. Did the driver violate the alcohol and controlled substances prohibitions under subpart B of §382?
No Yes
8. Did the driver fail to undertake or complete a rehabilitation program prescribed by a substance abuse professional (SAP) pursuant to §382.605 or 49 CFR part 40, subpart O?
N/A No Yes
9. For a driver who successfully completed a SAP's rehabilitation referral, and remained in the employ of the referring employer, did the driver have any of the following testing violations subsequent to completion of a §382.605 or 49 CFR part 40, subpart O SAP referral:
(A) Alcohol tests with a result of 0.04 or higher alcohol concentration? N/A No Yes (B) Verified positive drug tests? N/A No Yes
(C) Refusals to test (including verified adulterated or substituted drug test results)? N/A No Yes
BACKGROUND CHECK AUTHORIZATION
FMCSA DRUG & ALCOHOL TESTING & SAFETY PERFORMANCE INFORMATION
Safety Performance History In the previous three years, has the driver had any accidents, Uas defined by §390.5 of DOT regulations?
If yes, please attach all information as required by §390.15 (b)(1), as well as information on accidents you may wish to provide pursuant to §390.15 (b)(2) or your internal company policies.
No
Yes
Name of person providing information in Section II:
Phone #:
Title:
Date:
1608 E HWY 66, El Reno, OK 73036 | PO Box 451 El Reno, OK 73036 | P: 405.295.9005 | F: 405.295.9011 | www.nsightok.com
THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS
IMPORTANT DISCLOSURE
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service
In connection with your application for employment with (“Prospective Employer”), Prospective
Employer, its employees, agents or contractors may obtain one or 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 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 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 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 the 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 the report and may dispute with the FMCSA the accuracy or completeness of any information or
report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 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.
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. You may challenge the accuracy of the data by submitting a request
to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct
this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.
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 Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will
also appear, and remain, on a PSP report.
The Prospective Employer cannot obtain background reports from FMCSA without your authorization.
AUTHORIZATION
If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:
I authorize (“Prospective Employer”) to access the FMCSA Pre-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 authorizing 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.
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 challenge crash or inspection information reported by a State, FMCSA
cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for
adjudication.
I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report,
or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were
reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP
report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and
remain, on my PSP report.
I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I
understand that if I sign this Disclosure and Authorization, 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.
Date: _
Signature
_
Name (Please Print)
NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of
Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to
obtain an Applicant’s written or electronic consent prior to accessing the Applicant’s PSP report. Further, account holders
are required by FMCSA to use the language contained in this Disclosure and Authorization form to obtain an Applicant’s
consent. The language must be used in whole, exactly as provided. Further, the language on this form must exist as one
stand-alone document. The language may NOT be included with other consent forms or any other language.
NOTICE: The prospective employment concept referenced in this form contemplates the definition of “employee”
contained at 49
C.F.R. 383.5.
LAST UPDATED 12/22/2015
Cementing – Acidizing – Pressure Pumping – Bulk Acids – Specialty Chemicals
Applicant, Please hand deliver this application or scan and email it back to me, my email address is below. I prefer this to be in a single document, in a pdf format. Our offices are located just south of Interstate 40, west of Yukon, OK. 3675 S Alfadale Road
El Reno, OK. 73036 Directions, Interstate 40 and Hwy 81, 1 Mile South, 1 Mile East, ½ Mile North, East into yard. Be aware that this position requires that you pass a road test in tractor trailer with a manual split gear transmission. If you think this will be a problem for you, please call me and let’s talk. Having the Tankers Endorsement is mandatory prior to employment, obtaining the HazMat Endorsement within 45 days of employment is a condition to continue employment. Please attach a copy of your CDL, front and back and your DOT Medical Card. If you have your Safe-land PEC Card or TWIC certification, include it also. You must have verifiable driving history, if you attended a CDL Driving School, please attach documents from school showing graduation and driving hours accomplished. If you have had points applied against your MVR and taken courses to reconcile, attach those certificates. If you have recent multiple moving violations, you will be wasting your time by applying. Please feel free to call me during normal hours to discuss any questions or concerns you might have. Danney Edwards Spinnaker Business Development 918-633-0529 [email protected]
www.spinnakeroil.com