Mechanic at ECM Energy Services

Full Legal Name *

Current Address *

City, State, ZIP *

Previous Three Years Residency

Phone *

Email *

Resume *

Date of Birth *

Social Security Number *

Drivers License State *

Drivers License Number *

Drivers License Class *

Class A
Class B
Class C
Class D

Drivers License Expiration Date *

Drivers License Endorsements

Are you at least 21 years of age? *

Is there any reason you might be unable to perform the job for which you have applied? *

Do you have reliable transportation to and from work? *

Have you previously worked for ECM Energy Services? *

If so, which location and when?

Do you have any relatives currently employed by ECM? *

Yes
No

If so, please list.

How did you hear about this opportunity with ECM? *

If you chose "Referral" who referred you?

What shifts are you available to work? *

Rate of Pay expected? *

Employer #1 Name and Address/City/State/Zip *

Employer #1 Contact Person and Phone Number *

Position Held with Employer #1 *

Employer #1 Start and End Dates *

Employer #1 Salary/Hourly Rate during Employment *

While employed with Employer #1, was your job safety-sensitive in a DOT regulated mode subject to drug & alcohol testing requirements of 49 CFR Part 40? *

Reason for leaving Employer #1? *

Employer #2 Name and Address/City/State/Zip *

Employer #2 Contact Person and Phone Number *

Position Held with Employer #2 *

Employer #2 Start and End Dates *

Employer #2 Salary/Hourly Rate during Employment *

While employed with Employer #2, was your job safety-sensitive in a DOT regulated mode subject to drug & alcohol testing requirements of 49 CFR Part 40? *

Reason for leaving Employer #2? *

Employer #3 Name and Address/City/State/Zip

Employer #3 Contact Person and Phone Number

Position Held with Employer #3

Employer #3 Start and End Dates

Employer #3 Salary/Hourly Rate during Employment

While employed with Employer #3, was your job safety-sensitive in a DOT regulated mode subject to drug & alcohol testing requirements of 49 CFR Part 40?

Reason for leaving Employer #3?

Employer #4 Name and Address/City/State/Zip

Employer #4 Contact Person and Phone Number

Position Held with Employer #4

Employer #4 Start and End Dates

Employer #4 Salary/Hourly Rate during time of Employment

While employed with Employer #4, was your job safety-sensitive in a DOT regulated mode subject to drug & alcohol testing requirements of 49 CFR Part 40?

Reason for leaving Employer #4?

Employer #5 Name and Address/City/State/Zip

Employer #5 Contact Person and Phone Number

Position Held with Employer #5

Employer #5 Start and End Dates

Employer #5 Salary/Hourly Rate during Employment

While employed with Employer #5, was your job safety-sensitive in a DOT regulated mode subject to drug & alcohol testing requirements of 49 CFR Part40?

Reason for leaving Employer #5?

Employer #6 Name and Address/City/State/Zip

Employer #6 Contact Person and Phone Number

Position Held with Employer #6

Employer #6 Start and End Dates

Employer #6 Salary/Hourly Rate during Employment

While employed with Employer #6, was your job safety-sensitive in a DOT regulated mode subject to drug & alcohol testing requirements of 49 CFR Part40?

Reason for leaving Employer #6?

Employer #7 Name and Address/City/State/Zip

Employer #7 Contact Person and Phone Number

Position Held with Employer #7

Employer #7 Start and End Dates

Employer #7 Salary/Hourly Rate during Employment

While employed with Employer #7, was your job safety-sensitive in a DOT regulated mode subject to drug & alcohol testing requirements of 49 CFR Part40?

Reason for leaving Employer #7?

Employer #8 Name and Address/City/State/Zip

Employer #8 Contact Person and Phone Number

Position Held with Employer #8

Employer #8 Start and End Dates

Employer #8 Salary/Hourly Rate during Employment

While employed with Employer #8, was your job safety-sensitive in a DOT regulated mode subject to drug & alcohol testing requirements of 49 CFR Part40?

Reason for leaving Employer #8?

DISCLOSURE STATEMENT - If you do not disclose information, it could disqualify you from the position in which you are applying for. Please answer all following categories as accurately as possible.

Accident Record for the past 5 years or more - Please supply accident date, nature of accident, fatalities or injuries (if any). If none, please write 'None'. *

Traffic Convictions & Forfeitures (other than convictions) for the past 3 years or more. Please supply location, date, charge and penalty. If none, please write 'None'. *

Please select highest level of education *

Last School Attended - Name/City & State *

Previous 3 years: Driver's Licenses - State/License #/Type of License/Expiration Date *

Have you ever been denied a license, permit or privilege to operate motor vehicles? *

If yes, please explain in detail.

Has any license, permit or privilege ever been suspended or revoked? *

If yes, please explain further.

Please list past driving experience - Supply Class of Equipment/Type of Equipment (Van, Tank, Flat, Etc.)/Dates/Approx. # of Miles. If none, write "none".

List states operated in within the last 5 years *

Please select ALL training you have completed: *

CRIMINAL RECORD DISCLOSURE - Disclosure of a criminal record or pending charges will not necessarily disqualify you from employment consideration. Each offense will be evaluated on its own with respect to time, circumstances, seriousness and relation to the position you are applying. (continued in next section)

(Continued from previous) Omission of information, failure to respond to questions regarding criminal record or pending charges may disqualify you from employment consideration.

Have you EVER been convicted, plead guilty or no contest to a crime other than a minor traffic violation? Note: Crimes include misdemeanors, felonies and any other category w/ exception of traffic infractions. Driving under the influence with a license or with a suspended license is NOT considered a minor traffic offense. Info regarding records sealed by a court of law need not be disclosed. *

If yes, please list what category of crime and explain.

Do you have any deferred prosecutions? *

If yes, exlain in more detail.

Do you have any criminal charges pending? *

If yes, please explain.

List any trucking, transportation, or other experience that may help you in your work for this Company.

List courses & training you have other than what’s shown elsewhere in this application.

List any special equipment or technical materials you can work with (other than those already shown).

AUTHORIZATION TO OBTAIN INFORMATION Requesting Employer: ECM ENERGY SERVICES INC., WILLIAMSPORT, PA. Phone: (888) 523-9095 PART I – DOT DRUG AND ALCOHOL RELEASE I authorize, per 49 CFR Part 40, the release of information from my DOT regulated drug and alcohol testing records by the carriers (company/school) listed below for the sole purpose of transmitting such records to the above listed employer *

PART I CONTINUED - I authorize release of the following info concerning DOT d&a testing violations during the past 5 years: Alcohol tests 0.04 or higher, verified positive drug tests, refusals to be tested, other violations of DOT d&a testing regulations, info of d&a rule violations from previous employers, and doc's of RTD process following a rule violation. *

PART I CONTINUED- If any carrier listed furnishes info concerning the listed items above, I authorize that carrier to release and furnish the dates of my negative drug &/or alcohol tests &/or tests w/ results below 0.04 during the 3 year period & the name & number of the substance abuse professional who evaluated me. *

Please list your DOT Regulated Carriers (DOT EMPLOYERS/ SCHOOLS) from the past Five (5) years: COMPANY NAME, CITY, & STATE. If you have NOT performed any DOT function in the past 5 yrs, write 'NONE'.'. *

PART II – CONSUMER REPORT DISCLOSURE AND RELEASE In connection with your employment or application for employment (including contract for services), consumer reports may be requested from TEAM Professional Services. These reports may include the following types of info: names and dates of previous employers, reason for termination, work experience, accidents, and drugs/alcohol use.

PART II CONTINUED - You have the right to make a request to TEAM at 8165 South Mingo Rd, Suite 100, Tulsa, OK 74133 or by phone at 800-410-5219, to request the nature & substance of all information in its files on you at the time of your request, including the sources of info and the recipients of any reports on you that TEAM has furnished w/i the 2 year period preceding request.

PART II CONTINUED - I authorized, without reservation, TEAM, and any party or agency contacted by TEAM, to furnish the abovementioned information. This authorization does not apply to D&A information obtained under PART I or through FMCSA ClearingHouse. *

I PROVIDE CONSENT to ECM Energy Services to conduct a query of the FMCSA Commercial Driver’s License Drug and Alcohol Clearinghouse (Clearinghouse) to determine whether drug or alcohol violation information about me exists in the Clearinghouse. I also provide consent for additional limited queries per the guidelines set by the FMCSA Drug and Alcohol Clearinghouse. *

FMCSA NOTIFICATION OF DRIVERS RIGHTS: In compliance with 49 CFR Part §391.23 you have certain rights regarding the performance history information that will be provided to prospective employers. (Continued next section)

DRIVER RIGHTS CONTINUED - I) You have the right to review information provided by previous employers. II) You have the right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to prospective employers. III) You have the right to have a rebuttal statement attached to the alleged erroneous information, (continued)

DRIVER RIGHTS CONTINUED - if the previous employers and the driver cannot agree on the accuracy of the information. Drivers who have previous DOT regulated employement history in the preceding three years and wish to review previous employer-provdied investigative information must submit a written request to prospective employers. (continued next section)

DRIVERS RIGHTS CONTINUED - This may be done at any time, including when applying, or as late as 30 days after being employed or being notified of denial of employment. Prospective employers must provide this information within five business days of the written request. (continued next section)

DRIVER RIGHTS CONTINUED - If prospective employers have not yet received the requested information from he previous employer, then the five day deadline will begin when the requested safety performance history information is received. (continued next section)

DRIVER RIGHTS CONTINUED - If you have not arranged to pick up or receive the requested records within 30 days of prospective employers making them available. Prospective employers may consider you to have waived your request to review the record. Mark below to confirm your understanding of drivers rights. *

TO BE READ AND SIGNED BY THE APPLICANT - 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. Any misrepresentation given on this application shall be considered an act of dishonesty. *

Electronic Signature-- Type FULL NAME, SOCIAL SECURITY NUMBER and TODAY'S DATE. To be used as your electronic signature. *

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