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Personal Information
Date*
Name*
First Middle Last Suffix
Address*
Street Address Address Line 2 City State ZIP Code
Social Security Number*
Phone*
Email*
Enter Email Confirm Email
Are You 18 Years or Older?*
- Yes
- No
Are you authorized to work in the US?*
- Yes
- No
Have you worked for Center Coal Company before?*
- Yes
- No
Have you ever been convicted of or plead guilty or no contest to a felony?*
- Yes
- No
A "Yes" response will not necessarily disqualify a candidate from employment. The nature and seriousness of the offense, the date of the offense, the relevance of the offense to the specific position(s) and other factors will be considered.
Your highest academic level*

General Information
Position Applying For*
Date Able to Start*
Days Available for Work*
- Select All
- Sunday
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
Expected Wage (per hour)*

Equipment Operating Experience
use the plus button to the right to add more lines*
Type of Equipment Years of Experience

use the plus button to the right to add more lines

Driving Record Information
Drivers License No*
State*
Class*
Endorsements*
- D - Doubles
- H - Haz Mat
- N - Tanker
- P - Passenger
- S - School Bus
- X - Tank/Haz Mat
- None
No person will be considered for a position which requires the routine operation of a motor vehicle if any of the following offenses are shown on your Driving Record within the last two year period prior to the date of application: A) DUI or Actual Physical Control B) Reckless or Aggravated Driving C) Negligent Homicide or Manslaughter resulting from the Operation of a Motor Vehicle D) Driving Under Suspension or Revocation of Drivers License E) 3 or more Violations within the last 6 months, unless there have been No Other Violations for the past 12 months

Safety Information & Training
MSHA 8 Hr. Refresher*
- Yes, I can provide proof of completion
- No, I cannot provide proof of completion
Date
MSHA 24 Hr.*
- Yes, I can provide proof of completion
- No, I cannot provide proof of completion
Date
OSHA 10 Hr.*
- Yes, I can provide proof of completion
- No, I cannot provide proof of completion
Date
PEC*
- Yes, I can provide proof of completion
- No, I cannot provide proof of completion
Date
List All Safety Training Received in the Last 5 Yrs. (Type and Date)
In case of an emergency notify*
First Last
Phone*

References
Upload: References
Accepted file types: docx, pdf, Max. file size: 15 MB.
Reference #1
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Reference #2
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Reference #3
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*

Employment History
Upload: Cover Letter
Accepted file types: docx, pdf, Max. file size: 15 MB.
Upload: Resume
Accepted file types: docx, pdf, Max. file size: 15 MB.
Please include: Company Name, Phone Number, Address, Supervisor's Name, Job Title, Starting Salary, Ending Salary, Responsibilities, Start Date, End Date, & Reason for Leaving.
Company #1
Company Name*
Phone
Address
Street Address Address Line 2 City State ZIP Code
Supervisor's Name
First Last
Job Title*
Starting Salary
Ending Salary
Responsibilities*
Start Date*
End Date*
Reason for Leaving*
May we contact your supervisor for a reference?*
- Yes
- No
Company #2
Company name
Phone
Address
Street Address Address Line 2 City State ZIP Code
Supervisor's Name
First Last
Job Title
Starting Salary
Ending Salary
Responsibilities
Start Date
End Date
Reason for Leaving
May we contact your supervisor for a reference?
- Yes
- No
Company #3
Company name
Phone
Address
Street Address Address Line 2 City State ZIP Code
Supervisor's Name
First Last
Job Title
Starting Salary
Ending Salary
Responsibilities
Start Date
End Date
Reason for Leaving
May we contact your supervisor for a reference?
- Yes
- No

Drug Screening
Are You Willing To Take a Pre-Employment Drug Test?*
- Yes
- No
Consent*
I fully understand that the presence of and/or illegal drugs may cause my rejection from further consideration for employment with Center Coal Company.*
Consent*
I fully understand that refusal to submit to a Drug Screening Test will constitute voluntary withdrawal of my Application for Employment.*

Before Submitting*
I certify that all of the information I provided is true
I certify that my answers are true and complete to the best of my knowledge and authorize Center Coal Company to verify their accuracy and to obtain reference information on my work performance, as well as conducting criminal background checks, pre-employment drug test, and checking driving records. I waive any action against Center Coal Company based on statements made during these investigations.

If this application leads to employment, I understand that false or misleading information or any kind of omissions of facts called for on this application shall be considered sufficient basis for dismissal. I understand that should an employment offer be extended to me and accepted that I will fully adhere to the policies, rules and regulations of employment of the Employer. I understand that any employment offered is for an indefinite duration and at will and that either I or the Employer may terminate my employment at any time with or without notice or cause.

I acknowledge that the conditional offer of employment I may receive is contingent on my satisfactory completion of this background check and drug test. If the results of the background check or the drug test determine that I do not fit the conditions for employment, the conditional offer is revoked and I no longer will be considered a qualified candidate for employment.
Signature*

Entering your name here is your signature of agreement on this application.
Date*
Month
Day
Year

Interested in a position at Center Coal Co.?

Step 1 of 9

Personal Information

General Information

Equipment Operating Experience

Driving Record Information

Safety Information & Training

References

Reference #1

Reference #2

Reference #3

Employment History

Company #1

Company #2

Company #3

Drug Screening

Type of Equipment	Years of Experience