Mettiki Coal (WV), LLC Application Active

For 30 Days
APPLICATION FOR EMPLOYMENT
Date
(Complete this Form in Ink Only) Application
As an Equal Opportunity Employer, employment and advancement in the Company are determined by an individual’s qualifications and abilities without regard to race, color, Submitted
religion, national origin, sex, age, disability, protected veteran status, genetic information, or any other form of discrimination prohibited by law. This policy applies to all phases
of personnel activity including hiring, training, assignment, promotion and compensation. Date Available
For Work

PERSONAL DATA
Referred to Company by Ad College/School Private Agency ____________________________________________
State Agency Own Initiative Employee ________________________________________________

Name (First, Middle, Last) Position Applied for

Mailing Address Phone No. (including area code)

City State Zip Code Social Security Number

XXX – XX – _ _ _ _
In case of Name Address Phone No. (including area code)
Emergency Notify
Are you legally entitled to be Yes Are you at least Yes Are you willing to relocate? Yes Are you willing to travel? Yes ______%
Employed in the United States No 18 years of age No No No
Were you ever an employee of Yes If Yes Location Dates
this company, or one of its No
affiliates?

EDUCATION RECORD
Type of School Name and Location No Yrs. Did You Degree and Major
Attended Graduate
1.
High School
2.

1.
Vocational or
Trade School 2.

1.
College or
University 2.

1.
Post Graduate
Schooling 2.

SKILLS AND EXPERIENCE

Check the box or list machines, mechanical, electrical equipment or systems with which you have experience (use additional page if necessary)
Examples:
How Long? How Long?
(weeks, months, years) (weeks, months, years)
Continuous mining machine Prep Plant experience
Mantrip Longwall miner
Ram car (jack setter, shear, headgate)
Roof bolter Other
Scoop
Shuttle car

Yes
Do you have any computer skills? No List software applications you have experience with:
 EMPLOYMENT RECORD
(start with current or most recent employment and go backwards)

May we contact your present employer? Yes No

May we phone you with discretion at your present place of employment? Yes No Phone _________________________________

Employer Address Dates From (Mo./Yr.) To (Mo./Yr.)

Employed
Job Title or Position Supervisor’s Name Supervisor’s Title Mo. Salary Starting Ending
or Hourly
Wage
Primary Responsibilities Reason for Leaving Phone

Employer Address Dates From (Mo./Yr.) Dates

Employed Employed
Job Title or Position Supervisor’s Name Supervisor’s Title Mo. Salary Starting Ending
or Hourly
Wage
Primary Responsibilities Reason for Leaving Dates
Employed
Employer Address Dates From (Mo./Yr.) Dates
Employed Employed
Job Title or Position Supervisor’s Name Supervisor’s Title Mo. Salary Starting Ending
or Hourly
Wage
Primary Responsibilities Reason for Leaving Dates
Employed
Employer Address Dates From (Mo./Yr.) Dates
Employed Employed
Job Title or Position Supervisor’s Name Supervisor’s Title Mo. Salary Starting Ending
or Hourly
Wage
Primary Responsibilities Reason for Leaving Dates
Employed

REFERENCES
(Please list three personal or business references other than former employers or relatives)
Name Address Occupation Phone No. Check Results/Date

Are you known to schools/references by another name? If yes, by what name?

Yes No

I understand that in the event of a preliminary offer of employment, I will be required to furnish a copy of my birth certificate or other satisfactory documentary proof of date of
birth, and pass a Company physical examination. I also hereby authorize the Company to communicate with all schools, former employers, and personal references and to
otherwise investigate and confirm the facts as set forth above. I release all such persons and company, its parent and subsidiaries, directors, employees and their officers,
and agents from any claims from such inquiries and investigations.

I understand that all offers of employment are contingent on my producing legally required documentation to satisfy Form I-9 from the Department of Homeland Security, U.S.
Citizenship and Immigration Services.

I further agree and acknowledge that, as a part of the application process and during possible subsequent employment with the Company, I may be subject to alcohol and
drug screening.

I understand that acceptance of this application does not constitute a contract of employment, and I agree and acknowledge that if employed, my employment can be
terminated, with or without cause or notice, at any time by myself or the Company.

I affirm that all information provided by me on this application is true and complete and understand that willful or deliberate falsification of information on this application or
elsewhere during the application and pre-employment process is cause for rejection of this application or discharge from the company in the event I am hired.

_______________________________________________________ ________________________________________
Applicant’s Signature Date
 CERTIFICATIONS/QUALIFICATIONS
If you are Certified and/or Qualified in any of the areas shown below, please check the box to indicate whether your card was issued by
Maryland, West Virginia or Federal. Please attach photocopies of your cards or other proof of Certification/Qualification to the back of this
application.

Mine Foreman WV Federal Dust Sampling WV Federal

Fire Boss WV Federal Noise WV Federal

Belt Examiner WV Federal Training Instructor WV Federal

Shot Firer WV Federal EMT WV Federal

Gas Testing WV Federal Paramedic WV Federal

Hoisting Engineer WV Federal Fire Fighter Qualified Yes No

Surface High Voltage WV Federal Mine Rescue Qualified Yes No

U.G. High Voltage WV Federal ______________________________________________

Surface Low/Medium WV Federal ______________________________________________

U.G. Low/Medium WV Federal ______________________________________________

EQUIPMENT EXPERIENCE
Please check the box next to any equipment that you are trained to operate and then write in the manufacturer of that equipment. Rate your
skill level on the equipment that you have checked using skill ratings from 1 (Trainee) through 5 (Expert)
Use the back of the form if necessary.

Shuttle Car Mfg. ________________ Skill Rating 1 2 3 4 5 Comments: ______________________________________

Scoop Tractor Mfg. ________________ Skill Rating 1 2 3 4 5 Comments: ______________________________________

Roof Bolter Mfg.________________ Skill Rating 1 2 3 4 5 Comments: ______________________________________

L.W. Shearer Mfg.________________ Skill Rating 1 2 3 4 5 Comments: ______________________________________

Locomotive Mfg.________________ Skill Rating 1 2 3 4 5 Comments: ______________________________________

Conveyor Sys. Mfg.________________ Skill Rating 1 2 3 4 5 Comments: ______________________________________

_________________________________ Skill Rating 1 2 3 4 5 Comments: ______________________________________

_____________________________ ____ Skill Rating 1 2 3 4 5 Comments: ______________________________________

JOB SKILLS & EXPERIENCE

Please check the box next to any skills or experience that you have. Rate your skill level using skill ratings from 1 (Trainee) through 5 (Expert)
Use the back of the form if necessary.

Hydraulics Skill Rating 1 2 3 4 5 Comments: ______________________________________

Diesel Maintenance Skill Rating 1 2 3 4 5 Comments: ______________________________________

Solid State Circuitry Skill Rating 1 2 3 4 5 Comments: ______________________________________

PLC Programming Skill Rating 1 2 3 4 5 Comments: ______________________________________

Stick Welding Skill Rating 1 2 3 4 5 Comments: ______________________________________

Wire Feed Welding Skill Rating 1 2 3 4 5 Comments: ______________________________________

Cutting (Torches) Skill Rating 1 2 3 4 5 Comments: ______________________________________

Metal Fabrication Skill Rating 1 2 3 4 5 Comments: ______________________________________

_____________________________ Skill Rating 1 2 3 4 5 Comments: ______________________________________

_____________________________ Skill Rating 1 2 3 4 5 Comments: ______________________________________