Application

* = indicates a required field

Personal Information

*First NameMiddle Name*Last Name*Address 1Address 2*City*State*Zip Code*Email Address*Home PhoneCan you be reached at work?Work Phone

General Information

*Are you employed now?*What is the desired salary?*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?*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?
Driver's License ID 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 1 (mandatory)*School Name*School Location (City)*School Location (State)*Years Completed*Graduate/GED*Major Course of Study

School 2 (if applicable)School NameSchool Location (City)School Location (State)Years CompletedGraduate/GEDMajor Course of Study

School 3 (if applicable)School NameSchool Location (City)School Location (State)Years CompletedGraduate/GEDMajor Course of Study

Employment HistoryThis section must be completed even if you submit a resume.

Employer 1*Present (or most recent) Employer*Company Telephone*Company Address 1Company Address 2*Immediate Supervisor Name*Immediate Supervisor Title*May we contact this employer?If no, why not?*Date Employed From

*Date Employed To

*Position and/or duties performed*Reason for leaving

Employer 2Present (or most recent) EmployerCompany TelephoneCompany Address 1Company Address 2Immediate Supervisor NameImmediate Supervisor TitleMay we contact this employer?If no, why not?Date Employed From

Date Employed To

Position and/or duties performedReason for leaving

Employer 3Present (or most recent) EmployerCompany TelephoneCompany Address 1Company Address 2Immediate Supervisor NameImmediate Supervisor TitleMay we contact this employer?If no, why not?Date Employed From

Date Employed To

Position and/or duties performedReason for leaving

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

Personal Reference 1*First Name*Last Name*Phone Number*Address 1Address 2*City*State*Zip*Occupation/Title

Personal Reference 2*First Name*Last Name*Phone Number*Address 1Address 2*City*State*Zip*Occupation/Title

Personal Reference 3*First Name*Last Name*Phone Number*Address 1Address 2*City*State*Zip*Occupation/Title

Certificate / Qualification 1Name of Certificate / QualificationCertificate / Qualification NumberCertificate/Qualification State Issued
Certificate/Qualification Expiration Date

Certificate / Qualification 2Name of Certificate / QualificationCertificate / Qualification NumberCertificate/Qualification State Issued
Certificate/Qualification Expiration Date

Certificate / Qualification 3Name of Certificate / QualificationCertificate / Qualification NumberCertificate/Qualification State Issued
Certificate/Qualification Expiration Date

Certificate / Qualification 4Name of Certificate / QualificationCertificate / Qualification NumberCertificate/Qualification State Issued
Certificate/Qualification Expiration Date

AcknowledgementsMy 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.

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Application forEmployment

Application for
Employment