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EMPLOYMENT APPLICATION FORM

1

APPLICANT INFORMATION


Are you a citizen of the united states?
If no, are you authorized to work in the U.S.?
Have you ever worked for this company?
Have you ever been convicted of a felony?

EDUCATION


Do you have any kind of study?
Did you graduate?
Did you graduate?
Did you graduate?

REFERENCES

Please List three professional references

PREVIOUS EMPLOYMENT


Have you ever employment?
May we contact your previous supervisor for a reference?

May we contact your previous supervisor for a reference?

May we contact your previous supervisor for a reference?

MILITARY SERVICE


You did military service?

DISCLAIMER AND SIGNATURE


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 mis leading information in my application or interview may result in my release, I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

UPDATE DIGITAL SIGNATURE

DATE

2


B-MAC Company – General Laborer Policy






UPDATE DIGITAL SIGNATURE

DATE

3

Step 1:
Enter
Personal
Information

► Does your name match the name on your social security card? If not, to ensure you get credit for your earnings, contact SSA at 800-772-1213 or go to www.ssa.gov.


Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can. claim exemption from withholding, when to use the online estimator, and privacy.

Step 2:
Multiple Jobs
or Spouse Works

Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse also works. The correct amount of withholding depends on income earned from all of these jobs.
Do only one of the following.
(a) Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3–4); or
(b) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding; or
(c) If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option. is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld . . . . . ►  
Complete Steps 3–4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3–4(b) on the Form W-4 for the highest paying job.)

Step 3:
Claim
Dependents

If your income will be $200,000 or less ($400,000 or less if married filing jointly):
Multiply the number of qualifying children under age 17 by $2,000
Multiply the number of other dependents by $500
Add the amounts above and enter the total here

Step 4:
(optional)
Other
Adjustments

(a) Other income (not from jobs). If you want tax withheld for other income you expect this year that won’t have withholding, enter the amount of other income here. This may include interest, dividends, and retirement income . . . . . . . . . . . .
(b) Deductions. If you expect to claim deductions other than the standard deduction and want to reduce your withholding, use the Deductions Worksheet on page 3 and enter the result here. . . . . . . . . . . . . . . . . . . . . . .
(c) Extra withholding. Enter any additional tax you want withheld each pay period .

Step 5:
Sign
Here


Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.

UPDATE DIGITAL SIGNATURE

DATE

4

B-MAC COMPANY
EMPLOYEE DIRECT DEPOSIT INFORMATION

EMPLEOYEE NAME :

NAME OF BANK :

ACCOUNT NUMBER :

ROUTING NUMBER :

5

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.

I attest, under penalty of perjury, that I am (check one of the following boxes):
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9:
An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number
1. Alien Registration Number/USCIS Number:
OR
2. Form I-94 Admission Number:
OR
3. Foreign Passport Number:
Country of Issuance:

Preparer and/or Translator Certification (check one):

(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)

5.1

Employee Info from Section 1

List A
Identity and Employment Authorization
OR
List B
Identity
AND
List C
Employment Authorization




Signature of Employer or Authorized Representative
Today's Date (mm/dd/yyyy)
Title of Employer or Authorized Representative
Last Name of Employer or Authorized Representative
First Name of Employer or Authorized Representative
Employer's Business or Organization Name
Employer's Business or Organization Address (Street Number and Name)
City or Town
State
ZIP Code

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)
A. New Name (if applicable)
B. Date of Rehire (if applicable)
Last Name (Family Name)
First Name (Given Name)
M.I
Date (mm/dd/yyyy)

C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below
Document Title
Document Number
Expiration Date (if any) (mm/dd/yyyy)
I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.
Signature of Employer or Authorized Representative
Today's Date (mm/dd/yyyy)
Name of Employer or Authorized Representative

6

EMPLOYER INFORMATION


1. Federal Employer ID
    Number (FEIN)
2. State Employer ID
    Number *
3. Employer’s Name


4. Employer’s Address
5. Employer’s City
6. State
7. ZIP Code

8. Employer’s Payroll     Address (if different
    from above) *
9. Employer’s Payroll City
10. State
11. ZIP Code
12. Employer’s Telephone
13. Employer’s FAX
14. New Hire Contact
      Person *

EMPLOYEE INFORMATION


15. Social Security
Number (SSN)
16. First Day of Work
(Mo/Day/Yr) *
17. Employee First Name
18. Employee Middle Name
19. Employee Last Name

20. Employee Home Address
21. Employee City
22. State
23. ZIP Code
24. Employee
Foreign Address
25. City
26. Country
27. Postal Code
28. State Where Employee was hired
Employee DOB
(Mo/Day/Yr)
30. Employee’s Salary
($ and cents)
31. Salary (Check One)

7

Employee Acknowledgement

I acknowledge that l have received a copy of the company D.O.T./RSPA Alcohol Misuse Policy. i also acknowledge that the provisions of the Policy are part of the terms and conditions of my employment and that I agree to abide by them.
Date
Signature of employeed
Print Name
Employee Social Security #

7.1

APPLICANT DATA RECORD

As employers/government contractors, we comply with government regulations and affirmative action responsibilities.


501er to help us comply with government record keeping, reporting and other legal requirements, please fill out the APPLICANT DATA RECORD. We appreciate your cooperation.

 

Name

Last
First
Middle
 

Address

Number
Street
City
State
Zip
Phone (Area Code)
Government agencies require periodic reports on the sex, ethnic background, handicapped and veteran status of applicants. This data is for analysis and affirmative action only. Submission of information about a handicap is voluntary.

CHECK ONE:

CHECK ONE OF THE FOLOWING:

Race/Ethnic Group:

CHECK IF ANY OF THE FOLOWING ARE APPLICABLE:

 
Emergency contact
Relationship
 
Phone Number:
Signature
Date

7.2




B-MAC Corporation


6955E.Commerce “P.0.Box14362"Odessa, Texas79768" (432)3524905" Fax (866)810-2818

    July 15,2006

EMPLOYEE CONDUCT POLICY

B-MACCOMPANY, Odessa, Texas has adopted an EMPLOYEECONDUCT POLICY as part of their employee hire package. This policy states that as an employee of B-MAC COMPANY you will be. required to work out of town. While working out of town you are a B-MAC COMPANY representative and required to obey and abide all laws according to local and state authorities. If at any time improper conduct is exhibited toward and Hotel staff or management, Oil Company employees, or any business that B-MAC COMPANY is associated with, the employee will be immediately terminated.

     B-MACCOMPANY Representative
     Date
     EMPLOYEE
     Date
     WITNESS
     Date

7.3

I hereby acknowledge that l have been provided a copy of the addendum to B-Mac Co. Drug/Alcohol policy requirements. I understand that disciplinary action, up to and including termination, will result if l violate this policy.

Employee Signature
Date
Employee Printed Name
Social Security Number (last 4 digits)

Consent and authorization for disclosure to clients of B-Mac Co. of alcohol and drug test results and related information.

I hereby consent to disclosure by B-Mac Co. and its agents, including, but not limited to, any collecting andtestingagenciesofthetestresultsidentifiedaboveandanyrelatedinformationto clientsof8‐ Mac Co. and its authorized agents, assigns, or representatives.

Employee Signature
Date
Employee Printed Name
Social Security Number (last 4 digits)

PERSONAL INFORMATION


First Name

Last Name

Employee No.

Home Address.

Address (line 2)

City

State

Zip Code

Home Phone

Cell phone

Email

Date of Birth

Emergency Contact

First Name

Last Name

Relationship

Home Phone

Cell Phone

Work Phone

Email

Medical Information

Primary Physician

Medical Facility

Phone Number

Address

City

State

ZIP Code

Other information

8

DOT Drug/Alcohol History Check

Applicant Authorization to Release DOT Drug/Alcohol Test Results
SECTION 1: TO BE COMPLETED BY APPLICANT

Applicant/Employee:
Current Employer:
Address:
City:
ST:
Zip:
Phone:
Fax:
Email:

l understand that as a condition of hire with the above named "Company", that I must consent to the release of all DOT mandated drug and alcohol information from all of the employers for which I worked in a DOT safety-sensitive position, or for which I took a DOT pre-employment drug test, during the previous two (2) years as required by DOT Part 40.25, (or three (3) years as required by Part 391.23 for any driver of a commercial motor vehicle).

I hereby authorize the following previous employer/ company to furnish the DOT information requested in section 2 below.

Previous Employer:
Address:
City:
ST:
Zip:
Phone:
Fax:
Email:
Contact:
Dates of Employment:
To:

(Complete additional form for each previous DOT employer)

Certification: I have read and fully understand this authorization to release my previous drug and alcohol test information, identified by the questions below. to the Company listed above. l hereby acknowledge that failure to provide accurate information in response to this request for release of information could negatively affect my employment offer or subject me to disciplinary action up to and including termination if later discovered alter my employment with the Company begins.

Signature of Applicant

SSN

Date


Release of Previous Employer’s DOT Drug/Alcohol Testing Results

SECTION 2: TO BE COMPLETED BY PREVIOUS EMPLOYER

In accordance with DOT regulations, the Company, named above, is required to obtain ‐- and as a Previous Employer, you are required to release – DOT drug and alcohol information, listed below, concerning the Applicant/Employee, named above. This information request covers any period of employment of the Applicant/Employee by you going back 2 years (3 years for CMV drivers), from the date of this request. Please complete the following:

*Note: If “yes” for item 5, you must provide the previous employer’s report If you answered “yes” for item 6, you must also transmit the appropriate return-to‐duty documentation (e.g., SAP report(s), follow‐up testing record).

Name of Person Completing Form

Title

Phone

Date


‘A reproduction of this authorization shall be deemed as effective and valid as an original. Rev. 2012

EMPLOYMENT BACKGROUND CHECK DISCLOSURE AND AUTHORIZATION DISCLOSURE

Drug Screen Compliance & Clinical Laboratory (“Company”) may obtain information about you from ClearStar Logistics, Inc., PO Box 1003, Cumming, GA 30028, 877-796-2559, or another third-party consumer reporting agency, for employment purposes, including without limitation, for the purpose of evaluating you for employment, promotion, reassignment and retention as an employee, at any time prior to or during your employment, if applicable, and without giving you any further notice. Thus, you may be the subject of a background check, also known as a “consumer report” and/or an “investigative consumer report,” which may include information about your character, general reputation, personal characteristics, and/or mode of living. These reports may contain, without limitation, all or some of the following types of information about you: credit history, social security number verification, address and alias history, personal references, professional references, employment history, education history, licenses, certifications, motor vehicle records, driving records, criminal history, and civil court record history. Credit history will only be requested where such information is substantially related to the duties and responsibilities of the applied-for position. You the right to know whether a consumer report has been obtained about you; and you have the right to request a copy of any report obtained by Company, a copy of “A Summary of Your Rights Under the FCRA,” and a complete and accurate written disclosure of the nature and scope of any investigative consumer report obtained by Company. An investigative consumer report is information on an individual’s character, general reputation, personal characteristics, or mode of living is obtained through a personal interview with an information source. The nature and scope of the most common form of investigative consumer report obtained for employment purposes is an interview with a reference, employer, coworker, supervisor, or customer.

New York and Maine residents only: You have the right to inspect and receive a copy of any investigative consumer report requested by Company by contacting the consumer reporting agency identified above directly. You may contact the Company to request the name, address and telephone number of the nearest unit of the consumer reporting agency designated to handle inquiries, which the Company shall provide with 5 days

New York and residents only: Upon request, you will be informed whether or not a consumer report was requested by Company, and if such report was requested, informed of the name and address of the consumer reporting agency that furnished the report. By signing below, you acknowledge receipt of Article 23-A of the New York Correction Law.

Oregon residents only: information describing you rights under federal and Oregon law regarding consumer identity theft protection, the storage and disposal of your credit information, and remedies available should you suspect or find that the Company has not maintained secured records will be provided upon request.
Washington State residents only: you have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

Authorization

I acknowledge receipt of the Background Check disclosure and A Summary of Your Rights Under the FCRA, and certify that I have read and understand both documents. I hereby authorize Company to obtain background check information, including consumer reports and investigative consumer reports, about me from ClearStar Logistics, Inc., or another third-party consumer reporting agency, for employment purpose, including without limitation, for the purpose of evaluating you for employment, promotion, reassignment and retention as an employee, at any time prior to or during my employment, if applicable, and without giving me any further notice. To this end, I hereby authorize, without reservation, any credit bureau, creditor, employer, coworker, supervisor, customer, institution, school, collage, university, license or certificate grating entity, state department of motor vehicles, state department of revenue, court, governmental agency, law enforcement agency, information service bureau, insurance company, other record-keeping agency, person, administrator, organization, company, corporation, entity, and any other information sources, to furnish any and all background information requested by ClearStar Logistics, PO Box 1003, Cumming , GA 30028, 877-796-2559, www.clearstar.net, another third-party acting on behalf of Company, and/or Company itself, and regardless of whether the requested information was received from another source. I that a copy of this Authorization shall be as valid as the original.


New York residents only: By signing below, you acknowledge receipt of Article 23-A of the New York Correction Law.

Minnesota and Oklahoma resident only: please check this box if you would like to receive a copy of a consumer report if one is obtained by the Company.

California residents only: By signing below, you also acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW. Please check this box if you would like to receive a copy of an investigative consumer report or consumer credit report at no charge if one is obtained by the Company whenever you have a right to receive such a copy under California law.

Authorization Signature

Date

Date of Birth

Print First Name

Middle Name

Last Name

Social Security:

License Number and State:

ClearStar*