Harrison Oilfield Services, Inc.
1450 S. HWY 191
Moab, Utah 84532
(435) 259-6430
EMPLOYMENT APPLICATION
*If you are applying for and truck driving position you must provide a current copy of your motor vehicle
history report before your application will be review for employment.*
Name: ______________________________________________________ Date: ____________
Address: ____________________________ City: _____________ State: _______ Zip: _______
Home Phone: ___________________________ Cell Phone: ____________________________
Position(s) applying for: _________________________________________________________
Date you can start: ______________________ Desired Salary: __________________________
Have you ever been convicted of or charged with a felony? YES ____ NO _____
If yes, please explain details in full, including dates, details of offense(s) charged, location and disposition:
__________________________________________________________________________________________
Have you ever claimed a Workers Comp.? YES _____ NO _____ If yes, please explain and when: ___________
_________________________________________________________________________________________
Have you ever had a back injury, or any other injury? YES ______ NO _____If yes, please explain: __________
EMPLOYEMENT/ WORK HISTORY:
Employer: ____________________________________________ Supervisor: _______________________________
Address: ______________________________________________ Job Title: ________________________________
City/State/Zip: __________________________________________ Phone: __________________________________
Reason for Leaving: _____________________________________ Dates of employment: ______________________
Employer: ____________________________________________ Supervisor: _______________________________
Address: ______________________________________________ Job Title: ________________________________
City/State/Zip: __________________________________________ Phone: __________________________________
Reason for Leaving: _____________________________________ Dates of employment: ______________________
Employer: ____________________________________________ Supervisor: _______________________________
Address: ______________________________________________ Job Title: ________________________________
City/State/Zip: __________________________________________ Phone: __________________________________
Reason for Leaving: _____________________________________ Dates of employment: ______________________
REFERENCES:
NAME: __________________________________________ PHONE: ____________________________
NAME: __________________________________________ PHONE: ____________________________
NAME: __________________________________________ PHONE: ____________________________
EDUCATION:
High School: ____________________ Date attended: _________________ Diploma achieved: ___________
College Attended: ________________ Date attended: _________________ Diploma achieved: __________
College Attended: ________________ Date attended: _________________ Diploma achieved: __________
SPECIAL SKILLS:
Please describe any special skills and additional qualifications: __________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
CERTIFICATION OF APPLICANT:
I certify that all statements made in this application are true and correct and that any misstatement of
material facts may subject me to disqualification or dismissal. Also, I authorize verification of all statements
made in this application.
Signature: __________________________________________________ Date: ________________________
