Pimee - Application Form

Online Application

To attach your resume, see bottom of this form
Section A – Personal Data
First Name:	*
Initial:
Last Name:	*
Street:	*
City:	*
Postcode:	*
Home Phone:	*
Cell Phone:
Social Insurance Number:
Alberta Health Care Number:
Date of Birth:	*
Status:		Treaty Non-Status Other Metis
Emergency Contact Name:
Home Phone:
Cell Phone:
Driver's License Number:
Province:
Expiry:
Class:
Endorsements:
Restrictions:
Can you obtain a Driver's Abstract:		Yes No
Are you prepared to undertake Pimee's Pre-Hire Alcohol and Drug Test?		Yes No
Have you received any traffic convictions in the last 3 years?		Yes No
Have you been at-fault for a collision in the last 3 years?		Yes No
Has your license or driving privileges ever been revoked?		Yes No
Are you willing to relocate?		Yes No
Are you willing to work shift work?		Yes No
Are you willing to work extended work schedules? (Over 5 days work before days off)		Yes No
Are you able to meet deadlines?		Yes No
Have you ever received Treatment		Yes No
In the past employment, how do you rate your attendance?
Do you foresee any problems arriving at work on time?
Were you able to complete the work assigned to you in your past jobs?
How would you best describe safety?
Any additional comments:

Section B – Physical Data
List any physical limitations that may prevent you conducting labour work?
Are you physically capable of hard manual work? Yes No If no, why?
Have you ever been injured on the job?		Yes No
If yes, when and explain:
If injured, was it a WCB claim?		Yes No
If yes, which province?
How much time have you lost from work in the last 3 years due to injury?
Sickness?

Section C – Education / Training/Safety Certificates
Highschool:
Complete:
OR Grade:
OR GED:
Post Secondary:
Institution:
Program:
Year:
Check if you have any of these safety training certificate(s) and indicate expiry dates
First Aid/CPR:
H2S Alive:
Advanced CPR:
B.O.P.:
W.H.I.M.I.S.:
H2S Alive:
Air Brakes:
T.D.G.:
Rig Training (PITS) (taken at Nisku):

Section D – Employment Record
Complete the following for all former employment, starting with the most recent. Do not leave any employment “gaps”. If you must leave a gap, please explain under the Comments section.
Previous Employer 1
Previous Employer:
Location:
Contact Name:
Phone:
Position Held:
Reason for Leaving:
Employed from:
Employed to:
Previous Employer 2
Previous Employer:
Location:
Contact Name:
Phone:
Position Held:
Reason for Leaving:
Employed from:
Employed to:

Previous Employer 3
Previous Employer:
Location:
Contact Name:
Phone:
Position Held:
Employed from:
Employed to:
Comments:
List all equipment types that you have operated and the time that you operated them. If you have documented training to operate any of these types of equipment, please indicate.
Equipment:
Time Operated:
Special Training:
Equipment:
Time Operated:
Special Training:
Equipment:
Time Operated:
Special Training:
Equipment:
Time Operated:
Special Training:

Section E – Resume
Attach a Resume:

Section F – Certification / Permission Statement
By submitting this form I certify that I personally completed this application and that all information supplied is true and complete to the best of my knowledge. I authorize representatives of PIMEE WELL SERVICING LTD. to make such investigations and inquiries as may be necessary to arrive at an employment decision. I hereby release employers, schools, health care providers, and other persons from all liability in responding to inquiries and releasing information in connection with this application.