BOX 467 CUDWORTH SK S0K 1B0

Phone: (306) 256-3692 Fax: (306) 256-3274

Email: Website: www.greatplainsdrilling.net

Position sought (please circle): Driller Driller’s Helper Water Hauler Drill Push

Date available to start work: Referred by:

PERSONAL INFORMATION

Date: / Full Name:
Address (Box No , Street Address):
City: / Province: / Postal Code:
Home Phone: / Cell Phone: / Email Address:

Do you have a valid driver’s license? Yes ☐ No ☐ Class:

Do you have a valid First Aid Ticket? Yes ☐ No ☐ Expiry Date:

Do you have a valid Seismic Blaster Ticket? Yes ☐ No ☐ Expiry Date:

Are you legally entitled to work in Canada? Yes ☐ No ☐

Are you able to be away from home for long periods of time? Yes ☐ No ☐

Are you able to work 12 hour days, several days in a row? Yes ☐ No ☐

Are you able to work outside, even in extreme temperatures? Yes ☐ No ☐

Are you able to lift 80-100 lbs, several times a day? Yes ☐ No ☐

Are you physically fit and able to work in an environment where

there is zero tolerance for drugs or alcohol? Yes ☐ No ☐

Are you at least 18 years of age? Yes ☐ No ☐

EDUCATION AND TRAINING

Type of School / Name and location of school / Attainment
High School / Highest grade completed:
Post-Secondary (Business, trade, technical or other training) / Degree/Diploma/Certificate obtained:
Other relevant training or experience

WORK HISTORY

Employer / Address
(City, Prov.) / Employment dates / Main Duties

REFERENCES

May we contact your present/past employer? Yes ☐ No ☐

Name / Position Title / Relationship / Phone Number
1)
2)
3)

SELF DECLARATION (VOLUNTARY)

Do you have a disability which will affect your ability to perform any of the functions of the job for which you have applied? Yes ☐ No ☐

If your answer to the above question is “yes” please indicate what functions you cannot perform, and what accommodations could be made which would allow you to do the work adequately?

Great Plains Drilling is working toward a workforce that is representative of the public it serves. Please answer the following question.

Are you a person of Aboriginal Ancestry (Status Indian, Non-Status Indian, Metis, Inuit) Yes ☐ No ☐

STATEMENT BY APPLICANT

1.  I certify that the facts set forth in this employment application are complete and true. I understand that if I am employed, false statements on this application shall be considered sufficient cause for dismissal.

2.  I also give permission to Great Plains Drilling to obtain information regarding my previous employment or educational background.

3.  I acknowledge that I have applied for employment with Great Plains Drilling in a High Risk and Safety Sensitive Position and an offer of employment for this position is conditional on testing negative for any Controlled Substance and Alcohol. If I test non-negative I understand I can reapply for employment within 30 days. I also acknowledge that once I commence employment I will be required to undertake Controlled Substance and Alcohol testing as a requirement for this High Risk & Safety Sensitive Position, in order to maintain an efficient, productive, and safe workplace.

Signature of applicant Date

Please return completed applications to:

Fax: 1-306-256-3274 Email: