Employment Application Employment Application Federal law prohibits discrimination in hiring or employment on the basis of race, color, sex, religion, disability, national origin, citizenship, or on the basis of age. No question on this application is intended to secure information to be used for such discrimination. Proof of identity and work authorization will be required upon employment in accordance with federal regulations. KEENAN ENERGY plans to verify the accuracy of the statements you make on this application. This application will receive consideration for sixty (60) days. If you have not heard from KEENAN ENERGY within sixty days and wish to receive further consideration for employment, you must reapply in person. Name * First Last * Last Email * Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Contact Phone * Are you 18 years of age or older? * Yes No If less than 18 please list your Date of Birth * Are you legally eligible for employment in the U.S.? * Yes No Education Highest grade completed in high school * 6 7 8 9 10 11 12 Name of high school * Location of high school * Did you graduate from high school? * Yes No Highest grade completed in college 1 2 3 4 5 Name of college or university Location of college or university College or university major subject or course of study Name of business or trade school Location of business or trade school Business or trade school major subject or course of study Name of correspondence school Location of correspondence school Highest grade completed in graduate school 1 2 3 4 Name of graduate school Location of graduate school Graduate School major subject or course of study Did you graduate from graduate school? Yes No Please list any degrees obtained AN EQUAL OPPORTUNITY EMPLOYER Employment Position desired * Salary desired * Are you currently employed? * Yes No May we contact your current employer? * Yes No Have you applied here before? * Yes No When? * Are you restricted to working only certain hours of the day? * Yes No Indicate the hours you are available * Can you, at the time of employment, submit verification of your legal right to work in the US? * Yes No Are you restricted from working certain days of the week? * Yes No Indicate the days you are available. * M T W T F S S Can you work any shift available? * Yes No Employment Desired * Full-time Part-time When can you report for work? * WORK EXPERIENCE (beginning with the last or present employer first) Employed from Employed to Phone Number Company name Company Address Company Address Company Address Company Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Positions Held or Duties Performed Starting rate of pay Ending rate of pay Name of Supervisor at time of separation Reason for Leaving plus1 Add more work experiences minus1 Remove a reference Criminal Background Have you ever pleaded guilty to, “no contest” to, or been convicted of a crime other than a minor traffic violation? * Yes No Please state citation, date, and place where offense occurred. * (A “yes” answer will not automatically disqualify you from consideration.) Driving Information Do you have a current driver’s license? * Yes No License class License expires * License state * AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Has your driver’s license ever been suspended or revoked? * Yes No Please explain the circumstances * Do you have transportation available to and from work? * Yes No Please list all moving traffic violations in the past five (5) years Offense Location Date plus1 Add Another minus1 Remove This Special Skills What knowledge, special training or computer skills, and/or other qualifications have you acquired from employment or other experience? Include any specific equipment that you can proficiently operate. Relatives In Our Employment list any relatives you have that currently work for Keenan Energy Full Name Relationship plus1 Add Another minus1 Remove This References Give three references who are not relatives or former employers. Reference 1 Full Name * Occupation * Years Known * Phone Number * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Reference 2 Full Name * Occupation * Years Known * Phone Number * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Reference 3 Full Name * Occupation * Years Known * Phone Number * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Got a Resume? Attach It Below Drop a file here or click to upload Choose File Maximum file size: 2MB Affidavit I authorize, without liability, investigation of all statements in this application. I authorize all schools which I attended and all previous employers to furnish to KEENAN ENERGY my record, reason for leaving and all information they may have concerning me, and I hereby release them and KEENAN ENERGY from all liability for any damage whatsoever arising wherefrom. I understand that KEENAN ENERGY may investigate my driving record, criminal record, and credit history. I understand I may be notified if such an investigative report is obtained and that I will have the right to make a written request within a reasonable period of time for a complete and accurate disclosure of information concerning the nature and scope of the investigation. Following an offer of employment, and, as a continuing condition of employment should I be hired, KEENAN ENERGY may require that I submit to a medical examination. KEENAN ENERGY also reserves the right to require me to undergo drug testing prior to employment or at any time during my employment, to the extent permitted by law. I understand that in event of my employment by KEENAN ENERGY,, it shall be sufficient cause for dismissal if any of the information I have given in this application is false, misstated, or if I have failed to give any information herein requested. I understand that proof of identity and work authorization will be required upon employment in accordance with federal regulations. In event of my employment by KEENAN ENERGY ., I agree to abide by all present and subsequently issued rules of the Company. If I am employed, I agree that my employment with KEENAN ENERGY is at will of the Company, which means that KEENAN ENERGY has the right to discharge me for any reason whatsoever. I also understand that I may be terminated or laid off at the discretion of the Company. I expressly agree and understand that this is the entire agreement between KEENAN ENERGY and myself on the subject of discharge, termination and/or laid off, and it may be changed only by an agreement in writing, signed by the President of the Company. I agree to conform to the Company’s rules, and I also agree that I shall be subject to other conditions which KEENAN ENERGYmay adopt at its sole discretion. I affirm that the information on this application is true and complete. I understand and agree that, if hired, my employment is “at will.” This means that either I or the Company may end the employment relationship at any time and for any or no reason. Signature * signature keyboard Clear Todays Date * Δ This application form is also available as a printable pdf file. ABOUT KEENAN ENERGY About Us Links Service Areas NEED HELP? Credit ApplicationOrder FuelContact UsEmployment Application
