GENERAL APPLICATION INFORMATION What position are you applying for: Name: Address: City: State: Select One AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip: Telephone Number: Mobile Number: When can you start? Can you work weekends? Yes No Desired Salary: Are you at least 18 years of age and eligible to work in the United States? Yes No Have you ever worked for any of our companies? Yes No Are you on layoff and subject to recall? Yes No MINING EXPERIENCE Do you have a KY Underground card? Yes No No. Annual training current: Yes No Do you have a WV Underground card? Yes No No. Annual training current: Yes No Surface miner card? Yes No No. Annual training current: Yes No Other Certifications: Which of the following duties have you done and rate yourself on a scale (1-5) and how many years? Scoop 1 2 3 4 5 Yrs Exp. Low Track/ Fork–Lift 1 2 3 4 5 Yrs Exp. Man Trip/ Supply Motor 1 2 3 4 5 Yrs Exp. Stopping’s /Overcasts 1 2 3 4 5 Yrs Exp. Belts/Track Work 1 2 3 4 5 Yrs Exp. Face Equipment 1 2 3 4 5 Yrs Exp. Welding 1 2 3 4 5 Yrs Exp. COCNRETE/CONSTRUCTION EXPERIENCE Which of the following duties have you done and rate yourself on a scale (1-5) and how many years? Concrete Finisher 1 2 3 4 5 Yrs Exp. Concrete Formwork 1 2 3 4 5 Yrs Exp. Tying Rebar 1 2 3 4 5 Yrs Exp. Welding 1 2 3 4 5 Yrs Exp. Equipment Operator 1 2 3 4 5 Yrs Exp. Concrete Pump Operator 1 2 3 4 5 Yrs Exp. Core Drill Operator 1 2 3 4 5 Yrs Exp. EDUCATION High School: City: State: Select One AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Did you earn a diploma? Yes No College/Trade school: Did you graduate? Yes No Degree/Certificate obtained: Other educational training courses: EMPLOYMENT HISTOR Most recent employer first Company: Name of supervisor: May we contact them? Yes No Telephone number: Job Title: Location: Date of employment Start Date End Date Reason for leaving: Company: Name of supervisor: May we contact them? Yes No Telephone number: Job Title: Location: Date of employment Start Date End Date Reason for leaving: Company: Name of supervisor: May we contact them? Yes No Telephone number: Job Title: Location: Date of employment Start Date End Date Reason for leaving: REFRENCE LIST Name: Telephone: Relation: Name: Telephone: Relation: Name: Telephone: Relation: Send
