Today's Date

MM

DD

YYYY

Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you live in the Victoria, Texas area?

We ask this in the event that your listed address is not your current residence. Please note, we DO NOT currently offer per diem or relocation incentives for transient workers.

Yes

No, but would be willing to relocate

No, not looking to relocate

How did you hear about us?

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Employment Agency

Friend

Relative

Walk-In

Other

Date of Birth

MM

DD

YYYY

Home Phone

(###)

###

####

Work Phone

(###)

###

####

Cell Phone

(###)

###

####

May we contact you at work?

Yes

No

Do you have any friends or relatives who work for Patterson Well Service?

Yes

No

Have you ever been employed by Patterson Well Service?

Yes

No

Are you currently employed?

Yes

No

May we contact your present employer?

Yes

No

Upon employment, can you provide documentation establishing your identity and eligibility to be legally employed in the United States?

Yes

No

Are you at least 18 years of age?

Yes

No

Do you have a dependable means of transportation to and from work?

Yes

No

On what date would you be available to begin work?

MM

DD

YYYY

Check which schedule(s) you are available to work:

Full Time

Modified Full Time

Part Time

Are you currently on “lay off” status and subject to recall with another employer?

Yes

No

Are you under any signed confidentiality or non-compete agreement with any other company? If yes, please provide a copy for review if/when considered for employment.

Yes

No

Have you been convicted of a felony within the past seven (7) years? If yes, explain at interview. (Indicating “yes” will not automatically or necessarily eliminate you from consideration for employment.) *

Yes

No

Do you have a valid driver's license?

Yes

No

Type of License

Operator

Commercial

Have you had any accidents during the past three years?

Yes

No

Have you had any moving violations during the past three years?

Yes

No

I certify that answers given herein are true and complete to the best of my knowledge. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I hereby understand and acknowledge that any employment relationship with this company is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge the Employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized Executive of Patterson Well Service. If hired, I agree to abide by all rules, regulations, and operating procedures of Patterson Well Service. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I further authorize Patterson Well Service or any of its agents, to verify all or part of the information I have provided. I understand and authorize that this verification may include inquiry into my credit history; driving record; criminal and civil records; felony, misdemeanor, and deferred adjudication records; prior employment (including contacting prior employers); education (degree, GPA and attendance) as well as other public and non-public record information, including a consumer or investigative consumer report. If hired or contracted, this authorization shall remain on file and shall serve as ongoing authorization for the procurement of consumer reports at any time during my employment or contract period. I authorize the release of such information as may be necessary to verify the information I have provided. I release and hold harmless from all liability any individual or entity requesting or supplying information with respect to my application for employment. Selecting yes will be weighted as a signature by the applicant.

Yes

No