APPLICATION FOR EMPLOYMENT

PIONEER
SAND COMPANY INC.
Last Name Street Address City First

"PIONEER SAND CO. IS A DRUG FREE WORKPLACE"

5000 NORTHPARK DR., COLORADO SPRINGS, CO 80918 Middle

Incomplete Applications Will Not Be Considered.

Date Home Telephone

State

Zip

Alternate Telephone Social Security # Driver's License # Exp. Date _____/_____/_________ Medical Certification Exp. Date _____/_____/_________ Pay Expected

P E R S O N A L

Have you ever been employed at any Pioneer Sand Company or any of it's affiliates Yes Position Desired Are you available to work (check all apply) Full Time_____ Part Time_____ Overtime______ Weekends______ Holidays______ Temporary______ *Pioneer only employs persons who are legally eligible to work in the United States. If you are offered position, you will be asked to provide information that demonstrates you are legally eligible to work in the US. Telephone number to be used in the event of an emergency No If yes: Month/Year ____________ Location________________________ Location Desired

(
Name

)
Relationship

When will you be able to begin work?________________

Telephone number

List all addresses at which you have resided during the past three years, starting with the most recent.Per 391.21 (b)(3) C.F.R

R E S I D E N C E

From ____________________

To ____________________

Street Address ____________________________________________City ___________________________State__________Zip_____________ From ____________________ To ____________________

Street Address ____________________________________________City ___________________________State__________Zip_____________ From ____________________ To ____________________

Street Address ____________________________________________City ___________________________State__________Zip_____________ *Use additional sheets if necessary No. of Yrs Completed Did you Graduate? Yes No Yes No Yes No

E D School U C College A T Bus/Trade/Technical I O High School N

Name and Location of School

Course of Study

Degree or Diploma

List special training or skills (languarges, machine operation, etc) with a brief description of job application

1
S K 2 I 3 L L 4 S

5 6

EMPLOYMENT
Most Current Employer First
Company Name Street Address

Complete last 10 Years of Employement (Use an additional sheet if necessary)

Telephone ( From ) To Last Employed (month and year) Weekly pay Start Reason for Leaving Telephone ( ) To Last Employed (month and year) From Weekly pay Start Reason for Leaving Telephone ( ) To Last Employed (month and year) From Weekly pay Start Reason for Leaving Telephone ( ) To Last Employed (month and year) From Weekly pay Start Reason for Leaving Telephone ( ) To Last Employed (month and year) From Weekly pay Start Reason for Leaving Telephone ( ) To Last Employed (month and year) From Weekly pay Start Reason for Leaving

City, Sate, Zip Code Job Title and Describe Your Work Company Name Street Address

City, Sate, Zip Code Job Title and Describe Your Work Company Name Street Address

City, Sate, Zip Code Job Title and Describe Your Work Company Name Street Address

City, Sate, Zip Code Job Title and Describe Your Work Company Name Street Address

City, Sate, Zip Code Job Title and Describe Your Work Company Name Street Address

City, Sate, Zip Code Job Title and Describe Your Work

A Have you ever been convicted of a criminal offense (felony, misdemeanor, and municipal, except for parking and minor D traffic violations)? You must answer "yes" if you have entered into a plea agreement, including a deferred sentence or D deferred judgement arrangement, in connection with a criminal charge. If the conviction is the subject of records sealed or expunged under court order, you need not respond. Yes___No___. If your answer is yes for either question above, provide, I for each conviction or pending criminal proceeding: The date of conviction or the commencement of the pending criminal T proceeding, the name and address of the relevant court, and the nature of the offense involved. I O __________________________________________________________________________________________________ N __________________________________________________________________________________________________ A __________________________________________________________________________________________________ L I Yes No N In compliance with the Colorado Youth Employment Opportunity Act of 1971, Pioneer Sand Company, Inc., will not employ any "minor" F due to employment restrictions set forth in the act. The definition of "minor" in this case is any person under 18 years of age. O Are you a minor? Yes No
Are you able to perform the tasks and functions of the job which you applied for with or without reasonable accomodations?

COMMERCIAL MOTOR VEHICLE DRIVER APPLICANTS

Per Federal Motor Carrier Safety Regulation, 383.21, drivers of commercial motor vehicles should posess only one driver's license. I certify that I have read and understood the preceding statement and comply with this requirement. I also certify that the following is a true and complete list of traffic violations (other than parking violations) for which I have been convicted or foreited bond or collateral, a list of all vehicle accidents, and details pertaining to any permit or license denial, revocation, or suspension during the past 36 months. Signature _____________________________________________________Date_________________ *LIST ALL UNEXPIRED OPERATOR'S LICENSES OR PERMITS (1) State_______Number___________________Exp. Date____/____/______Class_____Endorsement_____ (2) State_______Number___________________Exp. Date____/____/______Class_____Endorsement_____ As required by Federal Motor Carrier Safety Regulation 391.21, state your date of birth ________________ * SUPPLY A DETAILED LIST OF ALL VEHICLE ACCIDENTS FOR THE PREVIOUS 3 YEARS, SPECIFYING DATE AND NATURE OF EACH ACCIDENT AND ANY FATALITIES OR PERSONAL INJURIES IF CAUSED. ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ *SUPPLY DETAILS OF ANY LICENSE OR PERMIT DENIAL, REVOCATION, OR SUSPENSION OF PRIVILEGES TO OPERATE A MOTOR VEHICLE, OR STATE THAT NO DENIAL, REVOCATION, OR SUSPENSION HAS OCCURRED ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ *LIST ALL MOTOR VEHICLE VIOLATION CONVICTIONS AND BOND OR COLLATERAL FORFEITS (EXPECT FOR PARKING) DURING THE PREVIOUS 3 YEARS. ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

S I G N A T U R E

This application form is intended for use in evaluating your qualifications for employment. This application is considered current for 90 days. In order to be considered for positions 90 days after submission, a new application must be filed. The Company strives to make hiring and other personnel decisions without regard to sex, rece, age, creed, religion. national origin, or disability in accordance with applicable law. Testing of job related skills may be required prior to employment. As a condition of employment, and after receipt of a conditional offer of employment, you will be required to authorize the release of information concerning, but not limited to; workman's compensation claims, motor vehicle driving records, criminal history and medical information. Worker's compensation and medical information will only be requested and used in compliance with Colorado and federal laws. Any legal licensing requirements must be secured and maintained as an employment condition. By my signature below, I certify that I have read and understood all questions and instructions in this form and that all answers I have given and statements made are true and accurate to the best of my knowledge and belief. I understand that false, inaccurate, or misleading information may be grounds for terminating the application process or employment, even if I did not know of the error or inaccuracy and regardless of when discovered by the Company. I authorize the Company and/or its agents to verify any of the information provided on this form or otherwise provided or obtained in the hiring process. I authorize all employers, schools, companies, agencies, and law enforcement authorities and their employees to release any information concerning my background and I release same from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs while on duty or on the Company's premises, whether the drugs are illegal under state or federal law, and reporting to work or working under the influence of alcoholic beverages or such illegal drugs are prohibited during my employment. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. I understand and agree that the employment with the Company is employment at will. This means that, if I am hired by the Company, the Company is free to terminate my employment at any time, with or without advance notice, and for any reason, and that I am free to resign from employment with the Company at any time, with or without advance notice, and for any reason. This application does not create an express or implied employment contract.

Signature______________________________________________________Date__________________

Applicants Do NOT Complete

REFERENCE CHECK
REFERENCE #1

For Pioneer Office Use ONLY

REFERENCE #2 REFERENCE #3

When did this individual work for your company?

What type of work was done?

How would you rate the quality of work?

What type of vehicle(s) were operated?

Was this individual involved in any traffic accidents? How many? Were they preventable? Did this individual violate any of your personnel or safety policies? If "yes" please explain

Why did this worker leave your company?

Is this personal eligible to rehire?