PCI Application for Employment

We are an Equal Opportunity Employer                          

 

Position applying for (hold the ctrl button to select multiple positions):

 

Date of application :     -- mm/dd/yy

Please provide the following information:

First name
Last name
Middle initial
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
Home Phone
E-mail

Social Security #:

If you are under 18, and it is required, can you furnish a work permit?

  Yes       No

If no, please explain:


Have you ever been employed here before?     Yes      No

If yes, give dates and positions:


Are you legally eligible for employment in this country?     

Yes       No

Date available for work: -- mm/dd/yy

What is your desired salary?

Type of employment desired: (may choose more than one)

Full-Time
Part-Time
Temporary
Seasonal
Educational Co-Op

Employment History

Provide the following information of your past four (4) employers,
assignments or volunteer activities, starting with the most recent.

Section 1

Organization
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone

From : -- mm/dd/yy     To : -- mm/dd/yy

Starting Job Title/Final Job Title:


Immediate Supervisor and Title:


May we contact for reference:     Yes      No      Later

Reason for leaving:


Hourly Rate/Salary:    

Section 2

Organization
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone

From : -- mm/dd/yy     To : -- mm/dd/yy

Starting Job Title/Final Job Title:


Immediate Supervisor and Title:


May we contact for reference:     Yes      No      Later

Reason for leaving:


Hourly Rate/Salary:    

Section 3

Organization
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone

From : -- mm/dd/yy     To : -- mm/dd/yy

Starting Job Title/Final Job Title:


Immediate Supervisor and Title:


May we contact for reference:     Yes      No      Later

Reason for leaving:


Hourly Rate/Salary:    

Section 4

Organization
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone

From : -- mm/dd/yy     To : -- mm/dd/yy

Starting Job Title/Final Job Title:


Immediate Supervisor and Title:


May we contact for reference:     Yes      No      Later

Reason for leaving:


Hourly Rate/Salary:    

Skills and Qualifications

Summarize any training, skills, licenses and/or certificates that may
qualify you as being able to perform job-related functions in the position
for which you are applying:


Educational Background (if job related)

High School:


Number of years completed:    

Did you graduate?     Yes      No

Course of Study:


College:


Number of years completed:    

Major/Degree:


Course of Study:


Other:


Number of years completed?    

Did you graduate?     Yes      No

Course of Study:    

References

Reference:

Name
Work Phone

Number of years known:    

Reference:

Name
Work Phone

Number of years known:    

Reference:

Name
Work Phone

Number of years known:    

PCI Applicant Statement

I certify that all information I have provided in order to apply for work with the employer is true, complete and correct to the best of my knowledge.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any  respect, will be sufficient cause to (i) cancel further consideration of this application, or (ii) immediately discharge me from the employer's service, whenever it is discovered. I also understand that, if employed, any falsified statements on this application shall be grounds for dismissal.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law.

I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to reapply and fill out a new application.

I understand and agree that, if hired, my employment is for no definite period and may, regardless of terms of payment of my wages and salary, be terminated at any time without prior notice and without cause.

If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied, oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer's president.

 

DO NOT MAIL THIS FORM UNTIL YOU HAVE READ AND UNDERSTOOD THE ABOVE APPLICANT STATEMENT.

I certify that I have read, fully understand and accept all terms of the
foregoing Applicant Statement.

Signature of Applicant:   

 Date: -- mm/dd/yy

 



OR

MAIL TO:                                                                                               800.628.0231
Petroleum Co-Ordinators, Inc. 
202 Rue Iberville

Suite 215

Lafayette, Louisiana 70508

Fax 337.232.8221
 

DO NOT WRITE BELOW THIS LINE

Interviewed By:

Date:

Remarks:
 
Neatness: Ability:
Hired      Position         

Department                         

Salary/Wage Date Reporting to work
Approved
Employment Manager:
Department Head:
General Manager: