B-mac Applicants

1

Last Name

First Name

M.I.

Date

Street Address

Apartment/Unit #

City

State

ZIP

Phone

Date Available to star work

Social Security No.

Date of Birth

Position Applied for

Are you a citizen of the united states?

NOYES

If no, are you authorized to work in the U.S.?

NOYES

Have you ever worked for this company?

NOYES

If so, when?

Have you ever been convicted of a felony?

NOYES

If yes, explain

Do you have any kind of study?

NOYES

High School

Address

From

Did you graduate?

NOYES

Degree

College

Address

From

Did you graduate?

NOYES

Degree

Other

Address

From

Did you graduate?

NOYES

Degree

Full name

RelationShip

Company

Phone

Address

Full name

RelationShip

Company

Phone

Address

Full name

RelationShip

Company

Phone

Address

Have you ever been employed?

NOYES

Company

Phone

Address

Supervisor

Job Tittle

Starting Salary

Ending Salary

Responsabilities

From

Reasons for leaving

May we contact your previous supervisor for a reference?

NOYES

If no, explain

Company

Phone

Address

Supervisor

Job Tittle

Starting Salary

Ending Salary

Responsabilities

From

Reasons for leaving

May we contact your previous supervisor for a reference?

NOYES

If no, explain

Company

Phone

Address

Supervisor

Job Tittle

Starting Salary

Ending Salary

Responsabilities

From

Reasons for leaving

May we contact your previous supervisor for a reference?

NOYES

If no, explain

You did military service?

NOYES

Branch

From

Rank at Discharge

Type of Discharge

If other than honorable, explain

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or mis leading information in my application or interview may result in my release, I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

UPDATE DIGITAL SIGNATURE

DATE

2

B-MAC Company – General Laborer Policy

Physical Requirements:

• Lift heavy and awkward objects – up to 60 lbs.
• Capable of working in outdoor weather and environmental conditions including extreme heat and humidity, extreme cold, and high-elevations.
• Work in awkward positions using respective motions such as dirt shoveling, compacting dirt, and breaking/shipping concrete.
• Bend, stretch, stoop, kneel, crawl, twist, climb ladders, and reach out on a regular basis.
• Remove concrete forms.
• Stand for extended periods of time – up to 11 hours per day, Breaks are given in 2.5 hr intervals.
• Provide assistance to craft workers – carrying tools and materials to work area.
• Clean and prepare site to eliminate potential hazards.
• Must have good hand-eye coordination.
• Use hands to handle, control, and feel objects and/or tools, or tools typically are:

• Jack hammers
• Dirt compactors
• Dirt shovels
• Chipping guns/hammers
• raming hammers/crow bars
____________________________________________________________________________________________________________________________

Have you had any previous injuries or medical conditions that would prevent you from performing these task:

Circle one: Yes No

IF YES
Please list below:

UPDATE DIGITAL SIGNATURE

DATE

3

Step 1:
Enter
Personal
Information

(a) First name and middle initial

Last name

(b) Social security number

Address

City or town, state, and ZIP code

► Does your name match the name on your social security card? If not, to ensure you get credit for your earnings, contact SSA at 800-772-1213 or go to www.ssa.gov.

Single or Married filing separately
Married filing jointly (or Qualifying widow(er))
Head of household (Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)

Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can. claim exemption from withholding, when to use the online estimator, and privacy.

Step 2:
Multiple Jobs
or Spouse Works

Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse also works. The correct amount of withholding depends on income earned from all of these jobs.

Do only one of the following.
(a) Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3–4); or
(b) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding; or
(c) If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option. is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld . . . . . ►

Complete Steps 3–4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3–4(b) on the Form W-4 for the highest paying job.)

Step 3:
Claim
Dependents

If your income will be $200,000 or less ($400,000 or less if married filing jointly):

Multiply the number of qualifying children under age 17 by $2,000

Multiply the number of other dependents by $500

Add the amounts above and enter the total here

Step 4:
(optional)
Other
Adjustments

(a) Other income (not from jobs). If you want tax withheld for other income you expect this year that won’t have withholding, enter the amount of other income here. This may include interest, dividends, and retirement income . . . . . . . . . . . .

(b) Deductions. If you expect to claim deductions other than the standard deduction and want to reduce your withholding, use the Deductions Worksheet on page 3 and enter the result here. . . . . . . . . . . . . . . . . . . . . . .

(c) Extra withholding. Enter any additional tax you want withheld each pay period .

Step 5:
Sign
Here

Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.

UPDATE DIGITAL SIGNATURE

DATE

4

B-MAC COMPANY
EMPLOYEE DIRECT DEPOSIT INFORMATION

EMPLEOYEE NAME :

NAME OF BANK :

ACCOUNT NUMBER :

ROUTING NUMBER :

5

Last Name (Family Name)

First Name (Given Name)

Middle Initial

Other Last Names Used (if any)

Address (Street Number and Name)

Apt. Number

City or Town

State

ZIP Code

Date of Birth (mm/dd/yyyy)

U.S. Social Security Number

Employee's E-mail Address

Employee's Telephone Number

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.

I attest, under penalty of perjury, that I am (check one of the following boxes):

1. A citizen of the United States

2. A noncitizen national of the United States (See instructions)

3. A lawful permanent resident (Alien Registration Number/USCIS Number):

4. An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy):
Some aliens may write "N/A" in the expiration date field. (See instructions)

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9:
An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number

1. Alien Registration Number/USCIS Number:

2. Form I-94 Admission Number:

3. Foreign Passport Number:

Country of Issuance:

Signature of Employee

Today's Date (mm/dd/yyyy)

Preparer and/or Translator Certification (check one):

I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.

(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my
knowledge the information is true and correct.

Signature of Preparer or Translator

Today's Date (mm/dd/yyyy)

Last Name (Family Name)

First Name (Given Name)

Address (Street Number and Name)

City or Town

State

ZIP Code

5.1

Employee Info from Section 1

Last Name (Family Name)

First Name (Given Name)

M.I

Citizenship/Immigration Status

List A
Identity and Employment Authorization

OR

List B
Identity

AND

List C
Employment Authorization

Document Title

Issuing Authority

Document Number

Expiration Date (if any) (mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any) (mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any) (mm/dd/yyyy)

Additional Information

Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States

The employee's first day of employment (mm/dd/yyyy)

(See instructions for exemptions)

Signature of Employer or Authorized Representative

Today's Date (mm/dd/yyyy)

Title of Employer or Authorized Representative

Last Name of Employer or Authorized Representative

First Name of Employer or Authorized Representative

Employer's Business or Organization Name

Employer's Business or Organization Address (Street Number and Name)

City or Town

State

ZIP Code

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)

A. New Name (if applicable)

B. Date of Rehire (if applicable)

Last Name (Family Name)

First Name (Given Name)

M.I

Date (mm/dd/yyyy)

C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below

Document Title

Document Number

Expiration Date (if any) (mm/dd/yyyy)

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.

Signature of Employer or Authorized Representative

Today's Date (mm/dd/yyyy)

Name of Employer or Authorized Representative

6

1. Federal Employer ID
Number (FEIN)

2. State Employer ID
Number *

3. Employer’s Name

4. Employer’s Address

5. Employer’s City

6. State

7. ZIP Code

8. Employer’s Payroll Address (if different
from above) *

9. Employer’s Payroll City

10. State

11. ZIP Code

12. Employer’s Telephone

13. Employer’s FAX

14. New Hire Contact
Person *

15. Social Security
Number (SSN)

16. First Day of Work
(Mo/Day/Yr) *

17. Employee First Name

18. Employee Middle Name

19. Employee Last Name

20. Employee Home Address

21. Employee City

22. State

23. ZIP Code

24. Employee
Foreign Address

25. City

26. Country

27. Postal Code

28. State Where Employee was hired

Employee DOB
(Mo/Day/Yr)

30. Employee’s Salary
($ and cents)

31. Salary (Check One)

Hourly Biweekly Weekly Monthly Semi-Monthly Yearly

7

Employee Acknowledgement

I acknowledge that l have received a copy of the company D.O.T./RSPA Alcohol Misuse Policy. i also acknowledge that the provisions of the Policy are part of the terms and conditions of my employment and that I agree to abide by them.

Date

Signature of employeed

Print Name

Employee Social Security #

7.1

Emergency contact

Relationship

Phone Number:

Signature

Date

7.2

B-MAC Corporation

6955E.Commerce “P.0.Box14362"Odessa, Texas79768" (432)3524905" Fax (866)810-2818

July 15,2006

EMPLOYEE CONDUCT POLICY

B-MACCOMPANY, Odessa, Texas has adopted an EMPLOYEECONDUCT POLICY as part of their employee hire package. This policy states that as an employee of B-MAC COMPANY you will be. required to work out of town. While working out of town you are a B-MAC COMPANY representative and required to obey and abide all laws according to local and state authorities. If at any time improper conduct is exhibited toward and Hotel staff or management, Oil Company employees, or any business that B-MAC COMPANY is associated with, the employee will be immediately terminated.

B-MACCOMPANY Representative

Date

EMPLOYEE

Date

WITNESS

Date

7.3

I hereby acknowledge that l have been provided a copy of the addendum to B-Mac Co. Drug/Alcohol policy requirements. I understand that disciplinary action, up to and including termination, will result if l violate this policy.

Employee Signature

Date

Employee Printed Name

Social Security Number (last 4 digits)

Consent and authorization for disclosure to clients of B-Mac Co. of alcohol and drug test results and related information.

I hereby consent to disclosure by B-Mac Co. and its agents, including, but not limited to, any collecting andtestingagenciesofthetestresultsidentifiedaboveandanyrelatedinformationto clientsof8‐ Mac Co. and its authorized agents, assigns, or representatives.

Employee Signature

Date

Employee Printed Name

Social Security Number (last 4 digits)

First Name

Last Name

Employee No.

Home Address.

Address (line 2)

City

State

Zip Code

Home Phone

Cell phone

Email

Date of Birth

First Name

Last Name

Relationship

Home Phone

Cell Phone

Work Phone

Email

Primary Physician

Medical Facility

Phone Number

Address

City

State

ZIP Code

Other information

8

DOT Drug/Alcohol History Check

Applicant Authorization to Release DOT Drug/Alcohol Test Results
SECTION 1: TO BE COMPLETED BY APPLICANT

Applicant/Employee:

Current Employer:

Address:

City:

ST:

Zip:

Phone:

Fax:

Email:

l understand that as a condition of hire with the above named "Company", that I must consent to the release of all DOT mandated drug and alcohol information from all of the employers for which I worked in a DOT safety-sensitive position, or for which I took a DOT pre-employment drug test, during the previous two (2) years as required by DOT Part 40.25, (or three (3) years as required by Part 391.23 for any driver of a commercial motor vehicle).

I have NOT worked in a DOT safety-sensitive position for a DOT regulated company in the past 2 years (3 years for CMV drivers. 5 years for pilots). Proceed to sign and date form below.

I have tested positive, or refused to test, on a DOT pre-employment drug or alcohol test for an employer who did not hire me in the past two years (3 years for CMV drivers, 5 years for pilots). Please specify the company for which this occurred below.

I hereby authorize the following previous employer/ company to furnish the DOT information requested in section 2 below.

Previous Employer:

Address:

City:

ST:

Zip:

Phone:

Fax:

Email:

Contact:

Dates of Employment:

To:

(Complete additional form for each previous DOT employer)

Certification: I have read and fully understand this authorization to release my previous drug and alcohol test information, identified by the questions below. to the Company listed above. l hereby acknowledge that failure to provide accurate information in response to this request for release of information could negatively affect my employment offer or subject me to disciplinary action up to and including termination if later discovered alter my employment with the Company begins.

Signature of Applicant

SSN

Date

Release of Previous Employer’s DOT Drug/Alcohol Testing Results

SECTION 2: TO BE COMPLETED BY PREVIOUS EMPLOYER

In accordance with DOT regulations, the Company, named above, is required to obtain ‐- and as a Previous Employer, you are required to release – DOT drug and alcohol information, listed below, concerning the Applicant/Employee, named above. This information request covers any period of employment of the Applicant/Employee by you going back 2 years (3 years for CMV drivers), from the date of this request. Please complete the following:

YES

1. Any DOT alcohol test results of 0.04 or greater?

2. Any DOT positive drug test results?

3. Refusal to submit to a DOT required drug / alcohol test? (incl. adulterated or substituted results)

4. Other violations of DOT drug and alcohol testing regulations?

5. Did a previous employer report a drug / alcohol rule violation to you?

6. If “yes” for any of the above items, did the employee complete the return-to-duty process?*

7. Was the Applicant/Employee employed by you but NOT subject to DOT regulations?

*Note: If “yes” for item 5, you must provide the previous employer’s report If you answered “yes” for item 6, you must also transmit the appropriate return-to‐duty documentation (e.g., SAP report(s), follow‐up testing record).

Name of Person Completing Form

Title

Phone

Date

‘A reproduction of this authorization shall be deemed as effective and valid as an original. Rev. 2012

EMPLOYMENT BACKGROUND CHECK DISCLOSURE AND AUTHORIZATION DISCLOSURE

Drug Screen Compliance & Clinical Laboratory (“Company”) may obtain information about you from ClearStar Logistics, Inc., PO Box 1003, Cumming, GA 30028, 877-796-2559, or another third-party consumer reporting agency, for employment purposes, including without limitation, for the purpose of evaluating you for employment, promotion, reassignment and retention as an employee, at any time prior to or during your employment, if applicable, and without giving you any further notice. Thus, you may be the subject of a background check, also known as a “consumer report” and/or an “investigative consumer report,” which may include information about your character, general reputation, personal characteristics, and/or mode of living. These reports may contain, without limitation, all or some of the following types of information about you: credit history, social security number verification, address and alias history, personal references, professional references, employment history, education history, licenses, certifications, motor vehicle records, driving records, criminal history, and civil court record history. Credit history will only be requested where such information is substantially related to the duties and responsibilities of the applied-for position. You the right to know whether a consumer report has been obtained about you; and you have the right to request a copy of any report obtained by Company, a copy of “A Summary of Your Rights Under the FCRA,” and a complete and accurate written disclosure of the nature and scope of any investigative consumer report obtained by Company. An investigative consumer report is information on an individual’s character, general reputation, personal characteristics, or mode of living is obtained through a personal interview with an information source. The nature and scope of the most common form of investigative consumer report obtained for employment purposes is an interview with a reference, employer, coworker, supervisor, or customer.

New York and Maine residents only: You have the right to inspect and receive a copy of any investigative consumer report requested by Company by contacting the consumer reporting agency identified above directly. You may contact the Company to request the name, address and telephone number of the nearest unit of the consumer reporting agency designated to handle inquiries, which the Company shall provide with 5 days

New York and residents only: Upon request, you will be informed whether or not a consumer report was requested by Company, and if such report was requested, informed of the name and address of the consumer reporting agency that furnished the report. By signing below, you acknowledge receipt of Article 23-A of the New York Correction Law.

Oregon residents only: information describing you rights under federal and Oregon law regarding consumer identity theft protection, the storage and disposal of your credit information, and remedies available should you suspect or find that the Company has not maintained secured records will be provided upon request.
Washington State residents only: you have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

Authorization

I acknowledge receipt of the Background Check disclosure and A Summary of Your Rights Under the FCRA, and certify that I have read and understand both documents. I hereby authorize Company to obtain background check information, including consumer reports and investigative consumer reports, about me from ClearStar Logistics, Inc., or another third-party consumer reporting agency, for employment purpose, including without limitation, for the purpose of evaluating you for employment, promotion, reassignment and retention as an employee, at any time prior to or during my employment, if applicable, and without giving me any further notice. To this end, I hereby authorize, without reservation, any credit bureau, creditor, employer, coworker, supervisor, customer, institution, school, collage, university, license or certificate grating entity, state department of motor vehicles, state department of revenue, court, governmental agency, law enforcement agency, information service bureau, insurance company, other record-keeping agency, person, administrator, organization, company, corporation, entity, and any other information sources, to furnish any and all background information requested by ClearStar Logistics, PO Box 1003, Cumming , GA 30028, 877-796-2559, www.clearstar.net, another third-party acting on behalf of Company, and/or Company itself, and regardless of whether the requested information was received from another source. I that a copy of this Authorization shall be as valid as the original.

New York residents only: By signing below, you acknowledge receipt of Article 23-A of the New York Correction Law.

Minnesota and Oklahoma resident only: please check this box if you would like to receive a copy of a consumer report if one is obtained by the Company.

California residents only: By signing below, you also acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW. Please check this box if you would like to receive a copy of an investigative consumer report or consumer credit report at no charge if one is obtained by the Company whenever you have a right to receive such a copy under California law.

EMPLOYMENT APPLICATION FORM

1

APPLICANT INFORMATION

EDUCATION

REFERENCES

PREVIOUS EMPLOYMENT

MILITARY SERVICE

DISCLAIMER AND SIGNATURE

UPDATE DIGITAL SIGNATURE

DATE

2

B-MAC Company – General Laborer Policy

UPDATE DIGITAL SIGNATURE

DATE

3

Step 1: Enter Personal Information

► Does your name match the name on your social security card? If not, to ensure you get credit for your earnings, contact SSA at 800-772-1213 or go to www.ssa.gov.

Step 2: Multiple Jobs or Spouse Works

Step 3: Claim Dependents

Step 4: (optional) Other Adjustments

Step 5: Sign Here

UPDATE DIGITAL SIGNATURE

DATE

4

B-MAC COMPANY EMPLOYEE DIRECT DEPOSIT INFORMATION

EMPLEOYEE NAME :

NAME OF BANK :

ACCOUNT NUMBER :

ROUTING NUMBER :

5

5.1

Employee Info from Section 1

List A Identity and Employment Authorization

OR

List B Identity

AND

List C Employment Authorization

Signature of Employer or Authorized Representative

Today's Date (mm/dd/yyyy)

Title of Employer or Authorized Representative

Last Name of Employer or Authorized Representative

First Name of Employer or Authorized Representative

Employer's Business or Organization Name

Employer's Business or Organization Address (Street Number and Name)

City or Town

State

ZIP Code

Last Name (Family Name)

First Name (Given Name)

M.I

Date (mm/dd/yyyy)

Document Title

Document Number

Expiration Date (if any) (mm/dd/yyyy)

Signature of Employer or Authorized Representative

Today's Date (mm/dd/yyyy)

Name of Employer or Authorized Representative

6

EMPLOYER INFORMATION

1. Federal Employer ID Number (FEIN)

2. State Employer ID Number *

3. Employer’s Name

4. Employer’s Address

5. Employer’s City

6. State

7. ZIP Code

8. Employer’s Payroll Address (if different from above) *

9. Employer’s Payroll City

10. State

11. ZIP Code

12. Employer’s Telephone

13. Employer’s FAX

14. New Hire Contact Person *

EMPLOYEE INFORMATION

15. Social Security Number (SSN)

16. First Day of Work (Mo/Day/Yr) *

17. Employee First Name

18. Employee Middle Name

19. Employee Last Name

20. Employee Home Address

Step 1:
Enter
Personal
Information

Step 2:
Multiple Jobs
or Spouse Works

Step 3:
Claim
Dependents

Step 4:
(optional)
Other
Adjustments

Step 5:
Sign
Here

B-MAC COMPANY
EMPLOYEE DIRECT DEPOSIT INFORMATION

List A
Identity and Employment Authorization

List B
Identity

List C
Employment Authorization

1. Federal Employer ID
Number (FEIN)

2. State Employer ID
Number *

8. Employer’s Payroll Address (if different
from above) *

14. New Hire Contact
Person *

15. Social Security
Number (SSN)

16. First Day of Work
(Mo/Day/Yr) *

24. Employee
Foreign Address

Employee DOB
(Mo/Day/Yr)

30. Employee’s Salary
($ and cents)

As employers/government contractors, we comply with government regulations and affirmative action responsibilities.

501er to help us comply with government record keeping, reporting and other legal requirements, please fill out the APPLICANT DATA RECORD. We appreciate your cooperation.