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R. G. Johnson Application for Employment

Personal Information

* First Name

* Middle Name

* Last Name

* Address 1

Address 2

* City

* State

* Zip

* Email

* Home Phone

Can you be reached at work?

Work Phone

General Information

* Are you employed now?

* What is the salary desired?

* On what date would you be available for work?

* Have you completed the MSHA 32-Hour New Miner Training?

If you selected no, would you be willing to complete the training program prior to employment at RG Johnson?

You must provide proof of identity and employment eligibilty upon hire.

* Are you a U.S. citizen, lawful permanent resident or otherwise authorized to work in the U.S. without restriction?

You must provide proof of identity and employment eligibilty upon hire.

* Have you served in the U.S. Armed Forces?

Branch

* Present member of the National Guard or Reserves?

* Have you applied with us before?

Date of prior application:

How were you referred to R.G. Johnson?

* Are you willing and able to travel if your job requires it?

* Do you have a valid driver's license?

License Number

* Have you ever been fired or asked to resign?

Are you at least 18 years old?

Please list any crimes that you have been convicted of, excluding summary traffic offenses.

Education

* School Name/Location

* Years Completed

* Graduate/GED

* Major Course of Study

School Name/Location

Years Completed

Graduate/GED

Major Course of Study

LIST BELOW YOUR LAST THREE EMPLOYERS - MOST RECENT FIRST

This section must be completed even if you submit a resume.

Present or most recent employer:

Company Telephone:

Company Address 1:

Company Address 2:

Immediate Supervisor (Name & Title):

May we contact this employer?

If "no" why not?

Date Employed From:

Date Employed To:

Position or duties performed:

Reason for leaving:

Previous employer:

Company Telephone:

Company Address 1:

Company Address 2:

Immediate Supervisor (Name & Title):

May we contact this employer?

If "no" why not?

Date Employed From:

Date Employed To:

Position or duties performed:

Reason for leaving:

References

Give the names of three persons not related to you, whom you have known at least 1 year.

Personal Reference 1 Name

Personal Reference 1 Phone Number

Personal Reference 1 Address

Personal Reference 1 Occupation/Title

Personal Reference 2 Name

Personal Reference 2 Phone Number

Personal Reference 2 Address

Personal Reference 2 Occupation/Title

Personal Reference 3 Name

Personal Reference 3 Phone Number

Personal Reference 3 Address

Personal Reference 3 Occupation/Title

Certificate/Qualification 1 Name

Certificate/Qualification 1 Number

Certificate/Qualification 1 State Issued

Certificate/Qualification 1 Expiration Date

Certificate/Qualification 2 Name

Certificate/Qualification 2 Number

Certificate/Qualification 2 State Issued

Certificate/Qualification 2 Expiration Date

Certificate/Qualification 3 Name

Certificate/Qualification 3 Number

Certificate/Qualification 3 State Issued

Certificate/Qualification 3 Expiration Date

Certificate/Qualification 4 Name

Certificate/Qualification 4 Number

Certificate/Qualification 4 State Issued

Certificate/Qualification 4 Expiration Date

PLEASE READ AND ACKNOWLEDGE THE FOLLOWING STATEMENT BY INITIALING AFTER EACH PARAGRAPH AND SIGNING BELOW

My signature and initials below indicate that I have read, understand and agree to the following: (Please initial each paragraph)

* I have provided true and complete information in this application. Incomplete or false information, whenever discovered, may terminate my employment or consideration for employment.

* I authorize R.G. Johnson Company, Inc. to verify my suitability for employment and the information provided in this application with any person or organization listed in this application.

* In exchange for R.G. Johnson Company, Inc.'s consideration of this application, I release R.G. Johnson Company, Inc. and any persons, employers or organization listed in this application from all claims or liability for providing information or opinions to R.G. Johnson Company, Inc.

* I understand that if I am offered employment at R.G. Johnson Company, Inc., the offer will be conditioned upon passing a complete medical examination. I consent to such a medical examination including all tests believed by R.G. Johnson Company, Inc. to be helpful in evaluation of my suitability for employment. I release all medical information requested by R.G. Johnson Company, Inc. to help determine my capability to do the work for which I am applying.

* I understand that as a condition of employment, I am required to pass a drug screening exam. I consent to pre as well as post employment drug screening.

* Neither this application nor subsequent employment creates a contract or guarantee of employment for any period of time. Employment at R.G. Johnson Company, Inc. continues only as long as both I and R.G. Johnson Company, Inc. desire. Any modification of this arrangement must be in writing signed by the President of R.G. Johnson Company, Inc.

* This application shall remain active for six (6) months from today's date

* Regardless of my starting work schedule, I understand that I may be asked to work different shifts, weekends, and holidays. A refusal to do such work may result in my dismissal. My position with R.G. Johnson Company, Inc. is my primary job. Schedule conflicts or continued unavailability to work may lead to discipline including termination.

* No representative of R.G. Johnson Company, Inc. has made any representation or promises regarding my employment.

* If employed, I will follow all of R.G. Johnson Company, Inc.'s policies. My failure to do so could result in termination.

* Required field

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