PREEMPLOYMENT APPLICATION FORM

Addax Petroleum is an equal opportunity employer and adheres to principles and practices outlined in the Civil Rights Act of 1964, which prohibits discrimination in employment on the basis of race, sex, religion or national origin and Public Law which prohibits discrimination based on age. This application will be given every consideration, but its receipt does not imply that the applicant will be employed. Each question should be answered in a complete and accurate manner as no action can be taken on application until all questions have been answered. You are required to forward completed forms via email: recluta@addaxpetroleums.com

PERSONAL Todays Date________________________ Primary Phone (__ __ __)__ __ __ __ __ __ __ Email ____________________________

Area Code

Name _______________________________________________________________Alternative Phone (__ __ __) __ __ __ __ __ __ __

Last First Middle Area Code

Current Address _____________________________________________________________________________________________________No.StreetCityStateZip Social Security No. _______________________________ Are you 18 or older? Yes No

Drivers License: State_______ Number ____________________________Type___________ Exp. Date _____________________ Are you a U.S. citizen or do you have the legal right to be employed in the United States or Switzerland? Yes No Who should be contacted in case of emergency? ________________________________________________________Name

____________________Relationship ___________________________________________________No.StreetCityStateZip (__Area_____Code) __ __ __ __ __ __ __

EMPLOYMENT DESIRED Are you seeking FullTime PartTime Temporary or Contract Based? First Choice Position Applied for ________________________________________ Salary Desired Second Choice Position Applied for _____________________________________ Salary Desired Third Choice Position Applied for _______________________________________ Salary Desired Date and Notice period of joining a new firm ____________________________________________________ Have you ever applied before? Yes No
/Month

/Month

/Month

EDUCATION
Name, Address and Location Dates Graduate? Course Studied

High School College

From:

Yes No

Diploma: Degree:

Other

To: From:

Yes No Diploma:

To:

Yes No

If you did not graduate, why did you leave high school or college? ______________________________________________ _________________________________________________________________________________________________________________________ Are you are planning to further your studies? Yes No If so, when, where and what courses? ____________ _________________________________________________________________________________________________________________________ List all scholastic honors, offices held and activities involved in during high school and college______________ _________________________________________________________________________________________________________________________ List and describe any other School or Specialized Training _________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ MILITARY Have you ever served in the military? Yes No Service Branch_________________________________________________ Date Entered ______________________________________ Date Separated ________________________________________________ Final Rank _________________________________________ Are you a member of a reserve organization? Yes No

HEALTH Will you abide by the safety rules of this company? Yes No Are you willing to take a postplacement physical and urinary drug screen at company expense? Yes No

WORK HISTORY List names of employers in consecutive order with present or last employer listed first. Account for all periods of time including military service and any periods of unemployment. If selfemployed, give firm name and supply business references. PLEASE GIVE MONTH AND YEAR.
Name Of Employer Name and Title of Last Supervisor From: Dates Employed To: Month Annual Pay Starting $____________

Complete Address Including Zip Code

Month

Telephone Including Area Code ( ) Title

Nature of Business

Year ___________

Year ___________

Ending $___________ May we contact?

Reason for Leaving

Duties Name Of Employer

Name and Title of Last Supervisor

Dates Employed From: To: Month Month

Yes No Annual Pay Starting $____________

Complete Address Including Zip Code

Telephone Including Area Code ( ) Title

Nature of Business

Year ___________

Year ___________

Ending $___________ May we contact?

Reason for Leaving

Duties Name Of Employer

Name and Title of Last Supervisor

Dates Employed From: To: Month Month

Yes No Annual Pay Starting $____________

Complete Address Including Zip Code

Telephone Including Area Code ( ) Title

Nature of Business

Year ___________

Year ___________

Ending $___________ May we contact?

Reason for Leaving

Duties Name Of Employer

Name and Title of Last Supervisor

Dates Employed From: To: Month Month

Yes No Annual Pay Starting $____________

Complete Address Including Zip Code

Telephone Including Area Code ( ) Title

Nature of Business

Year ___________

Year ___________

Ending $___________ May we contact? Yes No

Reason for Leaving

Duties

GENERAL

Yes

No
May we contact your current employer for references? If hired, will you be able to work overtime? Will you be able to perform the essential job functions for the position you are applying for with accommodation? (Ask to see job description if one is not provided.) Have you ever been convicted of any crime? (Excluding convictions for marijuana related offenses for personal use more than two years old, convictions that have been sealed, expunged or legally eradicated, or misdemeanors for which probation was completed and the case was dismissed by court.) Note: A Yes response does not automatically disqualify your application. If Yes, please attach explanation. Are you currently out on bail or released on your own recognizance pending trial? If yes, please attach explanation.

CERTIFICATION & AUTHORIZATION

The above information is true and correct. I understand that the hiring process will be terminated, or in the event of my employment by the Company, I shall be subject to dismissal, if any information that I have given in this application, the background release form, in any resume or interview or any part of the hiring process is false or misleading, or if I have failed to give any information herein requested, or if I have withheld relevant information, regardless of the time elapsed after discovery. I authorize the Company to inquire into my educational, professional and past employment history references as needed to research my qualifications for this position. I hereby give my consent to any former employer to provide employment-related information about me to the Company and will hold the Company and my former employer harmless from any claim made on the basis that such information about me was provided or that any employment decision was made on the basis of such information. I also understand that criminal background and credit reports may be conducted in the course of the interview process or after, and I will be required to give authorization for such reports. I hereby acknowledge that I have read and agree to the above statements

Signature

Date