97 East 100 North 
Phone:
(435) 637-9300
Price
Mine Service Application
for Employment
PERSONAL INFORMATION:
Print Name
Social Security Number* ________-________-________Are you at least 18 years of age? Date of birth
*Note: Completion of social security number is optional. Failure to submit social security number on
this form will not prohibit employment consideration. Social security number
may be required on other forms prior to employment.
Current Address
Home Telephone Other Phone
E-Mail Address
FOR OUR REFERENCE:
Position Salary
Desired Desired
Are you presently employed? May we contact your present
employer?
GENERAL INFORMATION:
Are
you MSHA Certified ? □
Yes □ No Date Taken 32 Hour Class
Are you an experienced Miner? □ Yes □ No How many Years? ______________________________________
Annual
Refresher ? □ Yes □ No Date Taken last Annual Refresher
Have you ever been employed by Price Mine Service, Inc. □ Yes □ No
If yes, when
and at which mine? ___________________________________________________________________
Have
you ever applied with Price Mine Service before ? □ Yes □ No
When?
Do you have a valid driver’s
License? □ Yes □
No Class of license:
Driver’s License number and
issuing state: Expiration Date:
Are you willing to provide
your own transportation if necessary for your employment? □ Yes □
No
For purposes of compliance
with The Immigration Reform and Control Act, are you legally eligible for
employment in the
GENERAL INFORMATION:
Do
you have any physical or mental limitations, which would restrict your job
performance? □ Yes □ No
If
Yes Explain
_________________________________________________________________________________
Would
you be able to carry 50 – 75 lbs? For a distance of 100 yards if needed? □
Yes □ No
If
No Explain __________________________________________________________________________________
Have
you ever been injured on the job? □
Yes □ No
If
Yes, Explain: WHEN, WHERE, TYPE OF INJURY_________________________________________________
_____________________________________________________________________________________________
Do
you have a full doctors release? □
Yes □ No
Have you ever been convicted of a felony or, within the past two years, a misdemeanor that resulted in imprisonment?*
□ Yes □
No If yes, please provide the following:
Description of the offense:
County, City, Sate of Conviction:
*Note: An affirmative
response will not automatically disqualify you from being considered as a
candidate for employment, and other factors such as age and time of the
offense, seriousness and nature of the violation, and rehabilitation will be
taken into account.
MISCELLANEOUS EXPERIENCE/TRAINING:
List any specialized training
and/or certifications:
What equipment can you
operate?
Military Experience (Dates of
service, branch, rank, type of discharge:
List any computer skills and
software application proficiency:
List any foreign languages you
speak fluently:
EMPLOYMENT HISTORY:
Starting with the most recent, describe the four most recent
paid, military and applicable voluntary experiences. Highlight your knowledge, skills and
abilities which best demonstrate your qualifications for this position. You may list significantly different jobs
within the same organization as separate items.
|
Dates of Employment |
Employers Name, Address and Phone |
Salary |
Position |
Reason for Leaving |
|
From: To: |
|
|
|
|
|
From: To: |
|
|
|
|
|
From: To: |
|
|
|
|
|
From: To: |
|
|
|
|
EDUCATION:
Check highest grade completed □ 1 □
2 □
3 □
4 □
5 □
6 □
7 □
8 □
9 □
10 □
11 □
12 Year
Completed
If you did not complete high
school, do you have a high school equivalency diploma? □ Yes □ No Date
Received
Check number of years of post
high school education □ 1 □
2 □
3 □
4 □
5 □
6 □
7 □
8 (Detail in the space below)
|
Name and Location of Institution |
Hours |
Degree Received |
Major or Specialty |
Minor |
Dates Attended |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
REFERENCES:
List names, addresses and
relationships of three persons not related to you who know your qualifications.
|
Name |
Address |
Phone |
Relationship |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
We have offices in
Which location would you prefer working at?
Would you be willing to Re-locate? □ Yes □ No
We also work with companies that require traveling through
most States and
Each applicant will be given employment
consideration based on individual merit, without regard to the individual’s
race, color, religion, sex, national origin, the presence of a non-job related
medical condition or handicap, or other categories governed by applicable
law. We are an equal opportunity
employer.
APPLICANTS STATEMENT:
I hereby certify that the information in this application is
correct to the best of my knowledge and understand that falsification of this
information is grounds for refusal to hire, or if hired, dismissal. I authorize investigation of all statements
contained in this application. I
understand that this application is not intended to be a contract of employment. I understand and agree that my employment is
for no specific period of time and may, regardless of the date of payment of my
salary, be terminated at any time without previous notice.
SIGNATURE OF APPLICANT:
DATE:
Applicant may use the space
below for any additional comments: