Blue-Collar Graphics Privacy Statement

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614.330.0983

Date

Last Name

First Name

Middle Name

Street Address

City State Zip

Home Phone Alternate Phone

Are You At Least 18 Years Of Age? Yes No

If Hired, Can You Present Proof Of Your Legal Right To Work In The United States? Yes No

Have you been convicted of a criminal offense? Note: do not include convictions that have been annulled, erased, expunged, vacated, set aside, sealed by a court, or referred to a diversion program. Yes No If yes, please explain.

Have You Ever Worked For CCU Coal And Construction, LLC Or Oxford Mining Company In The Past? Yes No
If Yes, Date Of Previous Employment: Disposition:

Do You Have Any Relative(s) Or Person(s) With Whom You Are Involved In A Close Personal Relationship Employed By CCU Coal And Construction, LLC? Yes No
Name: Relationship:

Position(s) Desired Shift Desired
Hours Desired Date Available

EDUCATION & TRAINING
Professional Licenses:

License: License Number Issuing State Year Issued Expiration Date

License: License Number Issuing State Year Issued Expiration Date

License: License Number Issuing State Year Issued Expiration Date

License: License Number Issuing State Year Issued Expiration Date

Has Your License Ever Been Revoked Or Suspended? Yes No If yes, State Reason(s), Date(s) Of Revocation, And Date(s) Of Reinstatement:
Reason:

Date: Reinstatement Date:

Reason:
Date: Reinstatement Date:

Reason:
Date: Reinstatement Date:

EQUIPMENT OPERATION SKILLS
List the equipment you are qualified to operate, the number of years of experience for each, and whether you possess any special licenses, certificates, or training:
Equipment: Years: Special License, Certificate, Training:

Equipment: Years: Special License, Certificate, Training:

Equipment: Years: Special License, Certificate, Training:

Equipment: Years: Special License, Certificate, Training:

Equipment: Years: Special License, Certificate, Training:

Other Special Skills Or Training:

WORK EXPERIENCE
List the most recent employment first and list the past 10 years of employment. Use a separate sheet of paper if additional space is required.

Current Or Last Employer

Street Address

City
State Zip Phone

Start Date End Date

Title Final Wage

Reason(s) for Leaving

Position(s) Held

Supervisor Title

Mining Experience/Safety-Related Information
Have You Worked In A Coal Mining Operation Within The Last 5 Years? Yes No
If yes, list the last mine you worked in, and the date you left:

Do You Have A Current Coal Mine Safety Training Certificate? Yes No
If yes, Date: Trainer:

Does Your Training Certificate Include Surface & Coal? Yes No

Do You Have A West Virginia Class 07 Safety Card? Yes No

ACKNOWLEDGEMENTS & SIGNATURE
I certify that all of the information submitted by me on this application is true and complete, and I understand that any false information or omissions will lead to rejection of my application or, if I am employed, discipline up to and including termination at the time such false information or omissions are discovered.

I authorize investigation of all statements contained in this application, authorize CCU Coal And Construction, LLC to secure information about my background and experience with former employers, education institutions, and any relevant agencies and authorize those parties to provide information to CCU Coal And Construction, LLC concerning my background and experience. I release CCU Coal And Construction, LLC and all parties providing information to CCU Coal And Construction, LLC about my background and experience from any liability whatsoever arising therefrom.

I authorize CCU Coal And Construction, LLC to obtain information regarding my record with the Ohio Bureau of Motor Vehicles or other similar agency of another state if the job for which I am applying will require driving as part of my job duties.

My signature below certifies that I understand that if I am extended an offer of employment by CCU Coal And Construction, LLC, my employment is contingent upon satisfactory completion of a medical examination, including a drug test, and submission of proof that I have the credentials, experience, or licenses necessary for the position that I am offered. I further understand that if I refuse to take or fail the drug test, I am disqualified from further employment consideration. I hereby knowingly and voluntarily consent to CCU Coal And Construction, LLC’s request to undergo a drug test. I further release CCU Coal And Construction, LLC and its officers, agents, representatives, and employees from any and all claims and liability for damages associated with or arising from my submission to the medical examination and drug test.

I understand that if I am employed, my employment with CCU Coal And Construction, LLC may be terminated for any reason, with or without cause or notice, and at any time, by me or CCU Coal And Construction, LLC. Nothing in this application, or in any oral or written statement provided to me by CCU Coal And Construction, LLC or any of its agents will limit these rights to terminate my employment at will, and no one will have any authority to change this at-will relationship, unless such change is in writing, signed by the President of CCU Coal And Construction, LLC.

I understand that this application is only valid for the position applied for at present and that CCU Coal And Construction, LLC is not obligated to retain or consider this application for future openings.

APPLICANT SIGNATURE: ________________________________________ DATE: ______/______/________

THIS APPLICATION WILL ONLY BE CONSIDERED FOR THREE MONTHS. IF YOU HAVE NOT BEEN HIRED WITHIN 3 MONTHS OF FILLING OUT THIS APPLICATION AND YOU WISH TO CONTINUE TO BE CONSIDERED FOR EMPLOYMENT, YOU MUST COMPLETE ANOTHER APPLICATION.

© • Blue-Collar Graphics, LLC • 5835 Privilege Drive • Columbus, Ohio 43026 • 614.330.0983

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© Blue-Collar Graphics, LLC
5835 Privilege Drive
Columbus, Ohio 43026

614.330.0983

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