CHR.TEM.Form - Catalyst Handling



Application for EmploymentThis application form must be completed as accurately as possible. It is essential for the processing of your application for employment that all questions are answered.Each applicant must accept that no guarantee of employment is given by the completion of this form.Position Applied for: FORMTEXT ?????Date Applied: FORMTEXT ?????SECTION 1 – PERSONAL INFORMATION (Please Print)First Name(s): FORMTEXT ?????Social Security#: FORMTEXT ?????Surname: (Last Name) FORMTEXT ?????Date of Birth: FORMTEXT ?????Address: FORMTEXT ?????Mailing if Different from Above: FORMTEXT ?????Telephone No: FORMTEXT ?????Mobile: FORMTEXT ?????In case of accident, or sudden illness, please contact: Relationship: FORMTEXT ????? FORMTEXT ?????Phone: FORMTEXT ?????Name of Family Doctor: Phone: FORMTEXT ????? FORMTEXT ?????Address: FORMTEXT ?????Work Required:Full Time:Part Time:Casual: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoSECTION 2 – EDUCATION (Including University, Further Education, etc.) Name of School/College etc.FromToQualifications FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????QUALIFICATIONS:What Professional, occupational or trade qualifications do you hold?(Attach copies of certificates). FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????BASIC SAFETY ORIENTATION:Where: FORMTEXT ?????Date: FORMTEXT ?????SECTION 3 – EMPLOYMENT HISTORY (Start with the most recent position)Name of EmployerAddressLength of ServiceReason for LeavingFromTo FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????REFERENCES:Please give details of three references who may be contacted.Preferably two-week related references and one personal reference.NameAddressPhone NoOccupation1. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????2. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????3. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????MEMBERSHIP OF BUSINESS, PROFESSIONAL, SPORT OR ANY OTHER ORGANIZATIONName of OrganizationOffice Held (if any) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????What are your interests? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????What are your main strengths in terms of work ability and character? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????What are some of your weaknesses in terms of work ability and character? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????SECTION 4 – GENERALYesNoDo you object to enquiries being made of your past or present employers? FORMCHECKBOX FORMCHECKBOX Have you worked shift work before? FORMCHECKBOX FORMCHECKBOX Are you prepared to work shifts? FORMCHECKBOX FORMCHECKBOX Are you prepared to work on Saturdays? FORMCHECKBOX FORMCHECKBOX Are you prepared to work on Sundays? FORMCHECKBOX FORMCHECKBOX Are you prepared to work overtime? FORMCHECKBOX FORMCHECKBOX Are you prepared to travel for extended periods of time (perhaps interstate)? FORMCHECKBOX FORMCHECKBOX Do you have a current forklift license? FORMCHECKBOX FORMCHECKBOX Do you have a current driving license?If so, what classes? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX What other licenses do you hold (e.g. crane, rigging, confined space, boilermaker etc.)? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX Do you know any person currently employed by this Company?If so, who: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX Have you ever been convicted of a criminal offence?If so, give brief details: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX Are you awaiting the hearing of charges in a civilian court?If so, give brief details: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX Are you prepared to work as and where directed? FORMCHECKBOX FORMCHECKBOX Are you prepared to abide by Company and client safety and work rules? FORMCHECKBOX FORMCHECKBOX Have you previously been employed by this CHR?If so, when and in what capacity: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX Are you currently a member of the Armed Reserves? FORMCHECKBOX FORMCHECKBOX Are you legally entitled to work in the U.S.A? FORMCHECKBOX FORMCHECKBOX If not, do you have the right of permanent residence or a work permit? FORMCHECKBOX FORMCHECKBOX Are you a member of any union within the U.S.A?If so, which union? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX Many of our clients have drug and alcohol policies. Are you prepared to undergo alcohol and drug screening as part of your ongoing employment? FORMCHECKBOX FORMCHECKBOX If your application is accepted when could you commence employment? FORMTEXT ?????SECTION 5 – MEDICALConsistent with the Company’s Occupational Health and Safety obligations and given due consideration to the nature if work our Company undertakes you will (administrative personnel at the discretion of the General Manager) be required to undergo a medical examination, at the Company’s expense. Any offer of employment is conditional on this examination indicating that you are physically able to carry out the duties of the position.IF YOU ANSWER YES TO ANY OF THESE QUESTIONS PLEASE PROVIDE DETAILSYesNoComments/detailsAre you being treated by a Doctor for any illness FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Are you currently using any medication/tablets/drugs FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Do you wear glasses, contact lenses for reading / driving / working FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Have you experienced a cold, respiratory infection or ear discharge in the last 2 weeks FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Have you ever had an operation FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Are you receiving any medical treatment or taking any medication (including over the counter or herbal) FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Have you ever suffered a serious accident or injury FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Have you suffered an injury/illness in the past 12 months FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Have you ever made a claim for Workers Compensation FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Have you ever suffered from or do you now suffer from any of the following: FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Allergies (including any medication) FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Any form of kidney disease FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Any form of liver disease FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Arthritis, rheumatism FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Asthma, bronchitis or other lung disease, cough FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Back pain, sciatica, lumbago, slipped disc FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Blackouts, fits, epilepsy, funny turns FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Chest pain, angina FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Deafness, loss of heating, exposure to loud noise FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Diabetes FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Head injury, concussion FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Heart disease or heart surgery FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Hernia FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????YesNoComments/detailsHigh blood pressure FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Knee problems, cartilage injury FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Neck injury, whiplash FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????tuberculosis FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Do you smoke or have you ever smoked FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Have you ever been regularly exposed to: FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Chemicals FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Asbestos FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Other dusts FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Have you ever been prevented from a job because of a reaction to chemicals or dust FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Have you ever suffered from anemia or other blood disorder FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Have you ever suffered any form of skin rash/irritation, dermatitis FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Do you have a family history of diabetes, heart disease, cancer, asthma or eczema FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Do you have any condition that would prevent you from wearing supplied air breathing apparatus FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Is there any reason why you cannot wear safety or protective equipment (e.g. safety boots, gloves, ear muffs, safety glasses, etc.) FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Do you have any trouble with hearing or communication FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Do you use a hearing aid FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Have you ever been exposed to loud noise at work FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Are you exposed to loud noise outside work FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Do you have a history of deafness or ear problems FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Do any of your hobbies involve the use of paints, lead, solvents, pesticides and /or dusts FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????How many days’ absence have you claimed due to sickness during the last 12 months of employment? FORMCHECKBOX 0 FORMCHECKBOX 1-5 FORMCHECKBOX 6-10 FORMCHECKBOX 11-15 FORMCHECKBOX 16-20 FORMCHECKBOX Over 20 DaysSECTION 6 – DECLARATIONI, __ FORMTEXT ?????___________________________________ (full name) declare that to the best of my knowledge, the answers to the questions in this application are correct and I understand that any erroneous or false declaration made by me in this application may result in disciplinary action or possible dismissal.I also understand that the information requested is required to assist in determining suitability for employment with Catalyst Handling Resources LLC and should I gain a position, this information will form the basis of any personnel record.If my application for employment is successful, I will be bound by and will at all times observe and respect such terms and conditions of my employment and such policies and rules as may from time to time be promulgated, specified and otherwise stipulated by my employer.I understand that if my application is successful, my employment may be subject to a satisfactory medical report provided by a Medical Practitioner nominated by my employer (such examination will be paid for by the employer). I also understand that:The Company has a drug and alcohol policy that provides for pre-employment testing and testing during employment under certain conditionsConsent to and compliance with such policy is a condition of my employment; and Continued employment is based on successful passing of testing under such policy.I further understand that my employment relations with the Company are terminable at will for any reason by either party.Date: FORMTEXT ?????/ FORMTEXT ?????/ FORMTEXT ?????SignatureCatalyst Handling Resources LLC is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, gender, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with Catalyst Handling Resources LLC depends solely on your qualifications.SECTION 7 – ADDITONAL INFORMATION Do you have any further information that you would consider may assist your application? For example, personal and/or work achievements, interests, aspirations etc. If so, please attach additional information sheet to this application form.WAGE DEDUCTION AUTHORIZATION AGREEMENTI understand and agree that my employer, Catalyst Handling Resources, LLC, may deduct money from my pay from time to time for reasons that fall into the following categories:My share of the premiums for the Company’s group medical/dental plan if offered;Any contributions I may make into a retirement or pension plan sponsored, controlled or managed by the Company if offered;Installment payments on loans or wage advances given to me by the Company, and if there is a balance remaining when I leave the Company, the balance of such loans or advances;If I receive an over payment of wages for any reason, repayment to the Company, of such overpayments (the deduction for such a repayment will equal the entire amount for the overpayment, unless the Company and I agree in writing to a series of smaller deductions in specified amount);The cost to the Company of personal long-distance calls I may make on Company phones or on Company accounts, of personal faxes sent by me using Company equipment or Company accounts, or of non-work-related access to the internet or other computer networks by me using Company equipment or Company accounts;The cost of repairing or replacing any Company supplies, materials, equipment, money, or other property that I may damage (other than normal wear and tear), lose, fail to return, or take without appropriate authorization from the Company during my employment (except in the case of misappropriation of money by me, I understand that no such deduction may take my pay below minimum wage, or of I am a salaried exempt employee, reduce my salary below its predetermined amount) *;Any per diem, hotel, or flight cost that are incurred by the Company in order for me to work on a project and I do not complete the project without good cause or notify my supervisor of leaving the job;The cost of Company uniforms if I am terminated or resign and they are not returned in a timely manner;Administrative fees in connection with court-ordered garnishments or legally-required wage attachments of my pay, limited in extent to the amount or amounts allowed under applicable laws;If I use any Company credit or charge card for personal use or in any unauthorized way;If I take paid vacation or sick leave in advance of the date I would normally be entitled to it and I separate from the Company before accruing time to cover such advance leave, the value of such leave taken in advance that is not so covered;The value of any time off for absences to which paid leave is not applied (non-exempt salaried employees will have all such unpaid leave deducted from their salary, while exempt salaried employees will experience salary reductions only in units of a full day or week at a time, depending upon the exact nature of the absence, unless partial-day deductions are specifically allowed under federal law); andIf my employer pays any insurance premiums or retirement system contributions (“payments’) on my behalf that I would normally make under the applicable Company benefit plan, the amount of such payments made by the Company, such payments being an advance of future wages payable to me.I agree that the Company may deduct money from my pay under the above circumstances, or if any of the above situations occur. I further understand that the Company has stated its intention to abide by all applicable federal and state wage and hour laws and that if I believe that any such law has not been followed, I have the right to file a wage claim with appropriate state and federal agencies. FORMTEXT ?????Signature of EmployeeDate FORMTEXT ?????Employee’s Name - Printed FORMTEXT ????? FORMTEXT ?????Company RepresentativeDateAUTHORIZATION FOR RELEASE OF INFORMATIONIn connection with my application for employment (including contract for services) with Catalyst Handling Resources, I understand that investigative background inquiries are to be made on myself including consumer, criminal convictions, motor vehicle, and other reports. These reports will include information as to my character, work habits, performance and experience along with reasons for termination of past employment from previous employers. Further, I understand that you will be requesting information from various Federal, State and other agencies which maintain records concerning my past activities relating to my driving, credit, criminal, civil and other experiences.I hereby authorize Catalyst Handling Resources LLC, its corporate affiliates, its authorized agents and representatives (including any qualified vender) to verify all information contained in this form or in my application. I hereby release Catalyst Handling Resources LLC, its corporate affiliates, its authorized agents, representatives (including any qualified vender) and all others involved in this background investigation from any liability in connection with any information they give or gather and any decisions made concerning my employment based on such information. CA, MN & OK Residents please note: in Connection with your application for employment, your consumer report may be obtained and reviewed. Under California, Minnesota and Oklahoma law, you have the right to receive a free copy of your consumer report by checking the appropriate box below: FORMCHECKBOX Yes, I am a California resident and would like a free copy of my consumer report FORMCHECKBOX Yes, I am a Minnesota resident and would like a free copy of my consumer report FORMCHECKBOX Yes, I am an Oklahoma resident and would like a free copy of my consumer reportI hereby consent to your obtaining the above information from a qualified vender and/or any of their licensed agents. I understand to aid in the proper identification of my file or record the following information, as we as other information, as necessary.I also authorize Catalyst Handling Resources LLC to release a copy of their completed background check report to ExxonMobil and ExxonMobil representatives (NCMS).I understand that Catalyst Handling Resources LLC may periodically update the background check and I agree that I shall immediately inform Catalyst Handling Resources LLC of any conviction for a criminal offence arising subsequent to completion of the initial background check. I understand that failing to update Catalyst Handling Resources LLC to a new conviction may result in my removal from a client’s jobsite that require background checks.?Print Name: FORMTEXT ?????SS #: FORMTEXT ?????Date of Birth: FORMTEXT ?????Sex: FORMTEXT ?????Current Address: FORMTEXT ?????City/State/Zip: FORMTEXT ?????Driver’s Lic. #: FORMTEXT ?????State: FORMTEXT ?????Applications Signature: Date: FORMTEXT ?????ACKNOWLEDGEMENT OF COMPANY DRUG/ALCOHOL POLICYI hereby acknowledge I have been provided a copy of the addendum to Catalyst Handling Resources drug/alcohol policy requirements. I understand that disciplinary action up to and including termination will result if I violate this policy. FORMTEXT ?????Employee SignatureDate FORMTEXT ????? FORMTEXT ?????Employee Printed NameSocial Security Number (Last 4 Digits)CONSENT AND AUTHORIZATION FOR DISCLOSURE OF DRUG/ALCOHOL TEST RESULTSConsent and authorization for disclosure to clients of Catalyst Handling Resources of Alcohol and drug test results and related information.I hereby consent to disclosure by Catalyst Handling Resources, and its agents, including but not limited to any collecting and testing agencies, of the test results identified above and any related information to clients of catalyst Handling Resources and its authorized agents, assignees, or representatives FORMTEXT ?????Employee SignatureDate FORMTEXT ????? FORMTEXT ?????Employee Printed NameSocial Security Number (Last 4 Digits)?? ................
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