When completed please either fax to Attn: Blaine Pitre at (337) 989-8924 or email to
[email protected]
Authorization for Release of Information
PLEASE READ THE FOLLOWING CAREFULLY AND SIGN BELOW
Stric-Lan Companies, LLC
I hereby declare that the answers on this application are correct and that any misstatement or omission of fact will
be sufficient cause for rejection of my application or separation should I become employed by Stric-Lan
Companies, LLC. I authorize Stric-Lan Companies, LLC and its agents to contact any of my previous employers as
well as any reference source in order to verify the facts and information I have furnished regarding my
qualifications and character. I hereby authorize any person(s) having knowledge thereof to provide such
information to Stric-Lan Companies, LLC or its agents, and I hereby release from liability and agree to hold
harmless any person that furnishes such information in good faith. I authorize Stric-Lan Companies, LLC and its
agents to supply my employment record in whole or part and in confidence to any employer, insurance agency, or
other party with a legal and proper interest, and I hereby release Stric-Lan Companies, LLC and its agents who
furnishes such information. I further understand that my employment is for no fixed time and just as I am free to
resign at any time, Stric-Lan Companies, LLC reserves the right to terminate my employment at any time, with or
without cause and without prior notice. I understand that no employee, officer, or agent of Stric-Lan Companies,
LLC may bind it by oral or printed statements, including handbooks, benefits books, or bulletins, contrary to the
above.
I also declare that I am able to perform all essential functions of the position applied for in this application. I agree
that I will submit to a physical, ability, urinalysis, and/or blood or other examination requested by Stric-Lan
Companies, LLC at any time prior to or subsequent to my employment. I hereby release Stric-Lan Companies, LLC
or its agents from any liability resulting from any of the tests listed about and grant Stric-Lan Companies, LLC full
and free access to my medical records from pervious employment and/or my personal physician.
Under the provision of the Fair Credit Reporting Act, 15 U.S.G. Sec. 1681 et seq. Notice is hereby given that a
consumer report or investigative consumer report may be obtained which may include but not limited to: criminal
history, civil history, motor vehicle report, work history, workers compensation history, educational history,
information to your credit worthiness, character, general reputation, personal characteristics, and mode of living,
which will be used for employment purposes. An investigation into your worker’s compensation or industrial
accident background may also be conducted.
You are further advised under said Act that any person who produces or causes to be prepared an investigative
consumer report on any consumer, upon written request made by the consumer within a reasonable period of
time after the receipt by him/her of the disclosure required by subsection 1681 (d), shall make a complete and
accurate disclosure of the nature and scope of the investigation requested. This disclosure shall be made in
writing, mailed or otherwise delivered, to the consumer not later than five days after the date on which the
request for such disclosure was received from the consumer or such report was first requested, whichever is the
later.
You are further advised that if you are denied employment, either wholly or in part, because of information
contained in a consumer report at that term is defined in the Fair Credit Reporting Act, that a disclosure will be
made to you of the name and address of the consumer reporting agency making such report.
I have carefully read the information on this form, realize I have had the opportunity to ask questions about it, and
understand what it means.
Date of Birth: ______________________________
Signature of Applicant:____________________________
Drivers License No.:_________________________
Social Security # of Applicant: ______________________
State of Issue:_____________________
Date:____________________
EQUAL OPPORTUNITY EMPLOYER
LET THIS FORM AND/OR FAX OR COPY SERVE AS AN ORIGINAL
©Employers Resources, LLC 1984-2003
EMPLOYERS RESOURCES, LLC.
EMPLOYERS RESOURCES LONGSHORE, INC
P.O. BOX 61987
LAFAYETTE, LA 70596
(337)983-0702
(337)981-9305 FAX
www.employersresources.net
“You have questions. We have answers.”
Employee Screening Services Request Form
Company Name:
Stric-Lan Companies LLC
Applicant Name:
____________________________________________________________
Date of Request:
____________________________________________________________
Requestor:
Bill Nice
Type of Screen:
X
Company Basic package: criminal search felony & misdemeanor w/alias link
profile, motor vehicle report (MVR ODR), and DOT – Previous Employment Drug
and Alcohol release.
Optional/Other Services:

Criminal Index (national criminal search)

Civil Index (national civil court search)

Bankruptcy Index (national bankruptcy court search)

Appellate Court Index (national appeals court search)

Motor Vehicle Report (MVR/ODR)

National Driving Record (special forms required)

Education History Report (higher ed.)

DOT –Previous Employment Drug and Alcohol Release (special forms required)

Credit Profile

Professional License verification/certification check
SPECIAL INSTRUCTIONS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
AUTHORIZATION FOR RELEASE OF INFORMATION
I hereby authorize Stric-Lan Companies, LLC (hereafter “the Company” or “Employer”), its employees, agents,
private investigators, or any representative of the aforesaid company, to perform investigations into my
background, past behavior, to my character, general reputation, and mode of living including but not limited to:
Investigative Consumer Reports: I authorize the Company to perform investigative consumer reports that may
include credit reports, criminal history, or arrest records, worker’s compensation histories, motor vehicle records,
employment and unemployment records, military records, or other sources of information.
Education and Employment: I authorize schools, colleges, and all scholastic institutions to release any and all
information requested. This includes transcripts, grades, attendance records, and any other information
requested. I authorize all former and current employers to release any and all information regarding my
employment history. This includes all information contained in my personnel file, salary history, condemnations,
and all other pertinent information. I further authorize my supervisors and other work associates to disclose their
opinions and observations of my work habits, qualities, competency, and skills. Furthermore, I authorize full
disclosure of any and all drug and alcohol testing results.
Authorization and Understanding: I authorize custodians of the records of any agency, government agency, or
company as described above to release such information upon request of any investigator, agent, or
representative of the Company. I understand that any or all of these investigations or inquiries can be performed
prior to and periodically throughout the duration of my employment. I understand that the information requested
is for the use by the Company and may be re-disclosed only as authorized by law. I understand that I have the
right to request from the Company a written disclosure of the nature and scope of the investigation conducted
that I authorized above. If you are a Minnesota, California, or Oklahoma resident only and you want a copy of your
report, check here __. The reports will be mailed to you at the address below. I indemnify, release, and hold
harmless the Company, any agents of the Company, or others reporting to claims, defamation, demands, and/or
liabilities arising out of, or related to, such investigations, disclosures, or admissions. Copies and facsimile
transmissions of this authorization that show my signature are as valid as the original release signed by me.
TO BE COMPLETED BY APPLICANT
The following information is True and Correct to the best of my knowledge and is used for identification and
investigative purposes only.
PLEASE USE AN INK PEN AND PRINT CLEARLY.
Last Name
First Name
Middle Name
Current Address
City
Social Security Number
Date Of Birth
Drivers License Number
Other Last Names Used
Other States and Counties
I Have Lived
1.
2.
Applicant Signature:
Date:
To Be Completed By: (Client Name)
Department/Store Number:
 Criminal Records
County:____________
State:______________
County:____________
State:______________
County:____________
State:______________
County:____________
State:______________
 Federal Criminal Records
County:_____________
State:______________
County:_____________
State:______________
County:_____________
State:______________
 CHIPS!
 Social Security Number Trace
 Residential PLUS!
 Credit Report
 Motor Vehicle Record
 Worker’s Compensation History
State:_____________
State:______________
State:_____________
State:______________
 Employment Verification (Application Required)
 Do not verify current employer
 Professional License Verification:________________
 Educational Verifications (Application Required)
 National Wants and Warrants
 Sex Offenders Registry
 Prison Inmate Search
 Other/Special
Instructions:____________________________________
Client Signature:
Date
EMPLOYER, FAX THE COMPLETED FORM TO NCO/EBI (888)486-0731
©2002 Employment Background Investigations, Inc.
:
:
JOB DESCRIPTION CHECKLIST
The list below is a job description for a Well-Testing/Wireline Operator and Well-Test/Wireline Helper.
Please answer the following questions to the best of your ability by putting a check in either the yes or
no blanks. Please read carefully and sign the bottom.
YES
NO
___
___
Employee must be able to furnish his/her own transportation to the Stric-Lan office.
___
___
Employee must be available 24 hours a day, except while on vacation, or if
employee has assigned days off.
___
___
Employee must be able to be away from home for several consecutive days.
___
___
Employee must be able to read and write in regards to all forms, tests, signs, and other similar
items encountered on the job.
___
___
Employee must be able to ride boats for extended periods of time in calm and rough seas.
___
___
Employee must be able to fly on aircraft, fixed wing and rotor blade.
___
___
Employee must have a clean driving record. This includes no DWI’s in the past 6 years and no
more than 2 moving violations, or speeding tickets in the past year.
___
___
Employee must currently have a valid driver’s license.
___
___
Employee is subject to random illegal drug, weapon, alcohol searches, and drug and alcohol
testing while on Stric-Lan payroll.
___
___
Employee must be willing to follow all company rules including the removal to all jewelry while
working on the Stric-Lan payroll.
___
___
Employee must be able to tolerate extreme heat and extreme cold working conditions.
___
___
Employee must be able to work in excess of 12 hours per day if job requires him/her to do so.
___
___
Employee must be able to wear approved safety equipment. (Example: hard hat,
steel toe boots, safety glasses, life preserver, gloves, etc.)
___
___
Employee must be able to live in a smoke-free environment.
___
___
Employee must be able to support their own body weight. (Example: swing from 1 ½” rope from
a boat to fixed structure or vice versa for a minimum of 15 seconds.)
___
___
Employee must be able to lift 75 lbs., floor to waist, carry it 50 feet and return it to the floor.
___
___
Employee must be able to perform 3 minutes of overhead work.
___
___
Employee must be able to climb stairs with 16 steps carrying a 35 lb. toolbox using either right or
left hand.
___
___
Employee must be able to climb up and down ladders and wellhead equipment.
___
___
Employee must be able to work in job situations involving heights.
WARNING: PURSUANT TO LSA-R.S. 23:1208.1, I UNDERSTAND THAT THE FAILURE TO ANSWER TRUTHFULLY TO
ANY OF THE ABOVE QUESTIONS MAY RESULT IN A DENIAL OF ANY RIGHT I OR MY DEPENDENTS MAY HAVE TO
WORKERS’ COMPENSTION BENEFITS, INCLUDING MEDICAL TREATMENT AND EXPENSES.
I have read and fully understand the above.
__________________________________________
______________________________________
Applicant’s Signature
Approved By
Date
APPLICATION FOR EMPLOYMENT
We are an equal opportunity employer that considers all applicants for all positions without regard to race, color,
religion, creed, gender, national origin, age, disability, marital or veterans status, sexual orientation, or any other
legally protected status.
(PLEASE PRINT)
______________________________
NAME
________________________________________
ADDRESS
_________________________ ______________________
TELEPHONE NUMBER
SOCIAL SECURITY NUMBER
_____________________
DRIVER’S LICENSE NUMBER
POSITION DESIRED:_____________________________________________________________
_____________________________________________________________________________
REFERRED BY? ____________________________________________________
Are you at least 18 years of age?
Yes
No
Have you ever filed an application with us before?
___________________________
Yes
No
If yes, give date
Have you ever been employed with us before?
___________________________
Yes
No
If yes, give date
Are you currently employed?
Yes
No
May we contact your present employer?
Yes
No
On what date would you be available for work?
____________________________________________________________
Are you available to work:
Full Time
Have you ever been convicted of a felony?
Yes
Part Time
No
*See statement below*
An affirmative response does not preclude you from employment – All relevant circumstances
will be considered.
If yes, please explain
_____________________________________________________________________________
_____________________________________________________________________________
Page 1
EMPLOYMENT EXPERIENCE
Start with your present or last job. Include any job-related military service assignment and volunteer activities. You
may exclude organizations that indicate race, color, religion, gender, national origin, disabilities or other protected
status.
Employer
DATES EMPLOYED
FROM
HOURLY RATE/SALARY
TO
STARTING
ENDING
Telephone Number
Job Title
Supervisor
Reason for Leaving
Work Performed
Employer
DATES EMPLOYED
FROM
HOURLY RATE/SALARY
TO
STARTING
ENDING
Telephone Number
Job Title
Supervisor
Reason for Leaving
Work Performed
Employer
DATES EMPLOYED
FROM
HOURLY RATE/SALARY
TO
STARTING
ENDING
Telephone Number
Job Title
Supervisor
Reason for Leaving
Work Performed
Employer
DATES EMPLOYED
FROM
HOURLY RATE/SALARY
TO
STARTING
Telephone Number
Job Title
Supervisor
Reason for Leaving
Work Performed
IF YOU NEED ADDITIONAL SPACE, PLEASE CONTINUE ON A SEPARATE SHEET OF PAPER.
Page 2
ENDING
EDUCATION
NAME & LOCATION
COURSE OF STUDY
YEARS COMPLETED
OF SCHOOL
DIPLOMA OR
DEGREE?
HIGH SCHOOL
UNDERGRADUATE COLLEGE
GRADUATE PROFESSIONAL
OTHER (SPECIFY)
Describe any specialized training, apprenticeship and skills (Example: forklift experience).
REFERENCES
Name
Telephone Number
Address
Name
Telephone Number
Address
Name
Telephone Number
Address
APPLICANT’S STATEMENT
1.
2.
3.
4.
5.
I certify that answers given herein are true and complete to the best of my knowledge.
I authorize investigation of all statements contained in this application for employment as may be necessary in
arriving at an employment decision.
I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment
relationship with this organization is of an “at will” nature, which means that the employee may resign at any
time and the employer may discharge employee at any time with or without cause. It is further understood
that this “at will” employment relationship may not be changed by any written document or by conduct unless
such change is specifically acknowledged in writing by an authorized executive of this organization.
In the event of employment, I understand that false or misleading information given in my application or
interview(s) may result in discharge. I understand also that I am required to abide by all rules and regulations
of the employer.
I understand that my employment is conditional upon the results of the urine drug screen for which I will
submit a specimen for testing. I realize that any positive result not caused by the presence of a legitimately
prescribed prescription drug may be cause for my being refused employment or dismissal if results of the tests
are received after my initial employment date.
_____________________________________(signature)
Page 3
________________________(date)