31st roustabout training program...1 31st roustabout training program offered by: tanana chiefs...

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1 31 st Roustabout Training Program Offered by: Tanana Chiefs Conference Doyon Drilling, Inc. To be considered for the Roustabout training program, you must complete and sign all required documents and return them to Tanana Chiefs Conference Employment & Training *DEADLINE: FRIDAY, SEPTEMBER 30 th at 5 pm. APPLICATIONS MUST BE SUBMITTED BY DEADLINE *Applications received after this date and/or received incomplete by this date will not be considered. PLEASE REVIEW ALL DOCUMENTS AND SIGN APPLICATION AND INCOME VERIFICATION Document Checklist: 1. ____ APPLICATION 2. ____ HOUSEHOLD INCOME VERIFICATION (list all) 3. ____ IF AND ARE YOU ENROLLED INTO A ANCSA CORPORATION, IF SO WHICH ONE________________________ 4. ____ THE FOLLOWING IDENTIFICATION IS REQUIRED TO BE SUBMITTED WITH THIS PACKET: (Copies will be accepted) ONE of the following: AND a. Signed Social Security Card ONE of the following: b. Birth Certificate g. State ID Card c. BIA Certificate of Indian Blood h. Driver’s License d. TCC Tribal Enrollment Card i. School ID Card With Photo e. Voter Registration Card j. U.S. Military ID f. Village Tribal Enrollment Card 5. ____CURRENT RESUME (resume cannot replace application) 6. ____ TWO (2) LETTERS OF REFERENCE FROM FORMER EMPLOYERS 7._____COPY OF HIGH SCHOOL DIPLOMA OR EQUIVALENT 8._____CONFIDENTIAL INFORMATION REQUIRED FOR BACKGROUND CHECK 9._____SIGNED AUTHORIZATION FOR RELEASE OF INFORMATION 10. _____ENROLL & REGISTER WITH DOYON TALENT BANK @ WWW.DOYON.COM 11. _____MUST PROVIDE A CURRENT COPY OF CRIMINAL HISTORY Available through the Department of Public Safety/Alaska State Troopers for a fee of $25.00. An independent background check will be conducted by Doyon Universal Services. Incomplete applications will not be evaluated. 1. Mandatory Drug & Alcohol Testing. If you are selected to be interviewed, you will be tested. If you DO NOT pass the drug and alcohol test, you will not be eligible for the training. Below this DDI HR Staff Review Only ______________________________________________________________________________________________________________________ ____________________________________________ _________________________________ (Initial) DDI Staff Review Signature Date Office Review Completed: Y N (Circle)

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Page 1: 31st Roustabout Training Program...1 31st Roustabout Training Program Offered by: Tanana Chiefs Conference Doyon Drilling, Inc. To be considered for the Roustabout training program,

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31st Roustabout Training Program

Offered by: Tanana Chiefs Conference

Doyon Drilling, Inc.

To be considered for the Roustabout training program, you must complete and sign all required documents and return them to

Tanana Chiefs Conference Employment & Training

*DEADLINE: FRIDAY, SEPTEMBER 30th

at 5 pm.

APPLICATIONS MUST BE SUBMITTED BY DEADLINE

*Applications received after this date and/or received incomplete by this date will not be considered.

PLEASE REVIEW ALL DOCUMENTS AND SIGN APPLICATION AND INCOME VERIFICATION

Document Checklist:

1. ____ APPLICATION

2. ____ HOUSEHOLD INCOME VERIFICATION (list all)

3. ____ IF AND ARE YOU ENROLLED INTO A ANCSA CORPORATION, IF SO WHICH ONE________________________

4. ____ THE FOLLOWING IDENTIFICATION IS REQUIRED TO BE SUBMITTED WITH THIS PACKET:

(Copies will be accepted)

ONE of the following: AND

a. Signed Social Security Card ONE of the following:

b. Birth Certificate g. State ID Card

c. BIA – Certificate of Indian Blood h. Driver’s License

d. TCC Tribal Enrollment Card i. School ID Card With Photo

e. Voter Registration Card j. U.S. Military ID

f. Village Tribal Enrollment Card

5. ____CURRENT RESUME (resume cannot replace application)

6. ____ TWO (2) LETTERS OF REFERENCE FROM FORMER EMPLOYERS

7._____COPY OF HIGH SCHOOL DIPLOMA OR EQUIVALENT

8._____CONFIDENTIAL INFORMATION REQUIRED FOR BACKGROUND CHECK

9._____SIGNED AUTHORIZATION FOR RELEASE OF INFORMATION

10. _____ENROLL & REGISTER WITH DOYON TALENT BANK @ WWW.DOYON.COM

11. _____MUST PROVIDE A CURRENT COPY OF CRIMINAL HISTORY – Available through the Department of Public Safety/Alaska

State Troopers for a fee of $25.00. An independent background check will be conducted by Doyon Universal Services.

Incomplete applications will not be evaluated. 1. Mandatory Drug & Alcohol Testing. If you are selected to be interviewed, you will be tested. If you DO NOT pass

the drug and alcohol test, you will not be eligible for the training.

Below this DDI HR Staff Review Only

______________________________________________________________________________________________________________________

____________________________________________ _________________________________ (Initial)

DDI Staff Review Signature Date Office Review Completed: Y N (Circle)

Page 2: 31st Roustabout Training Program...1 31st Roustabout Training Program Offered by: Tanana Chiefs Conference Doyon Drilling, Inc. To be considered for the Roustabout training program,

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TIPS FOR FILLING OUT APPLICATION PACKET

The attached application packet you are about to fill out is very important. The information you

provide is a reflection of you, and the amount of work you put into it can determine whether or not

you are selected for an interview. By answering the questions fully and truthfully, you can

increase your chances for selection.

Examine the attached job description closely for the Roustabout position. Read this description

carefully, complete your resume and fill out the application to reflect your experience and capabilities

as they apply to the job description. Make sure that you list ALL work performed; including

volunteer work or work you have done around your community.

Keep in mind that the raters of the application and resume are sensitive to inconsistencies between the

application and the resume.

A good, concise, well organized and neat application package says something about you and your

willingness to do a good job!!

Be specific in your narrative. Tell us why you want to work in the oil field and why you think you

are qualified for this work. Explain technical and mechanical experience you have regardless of how

the experience was obtained.

The information you put in the application packet will determine whether you are selected to be

interviewed or not.

Think of questions to ask the interviewers.

Unprofessional conduct may be grounds for dismissal from the program.

Remember the oil field is not for everyone. Please take into account the isolation and the job

description BEFORE you apply. Your success in this program will benefit your family as well as the

Doyon Family of Companies!!!

PLEASE NOTE: If you are late or do not attend the Orientation the evening before your interview, you

will be disqualified for your interview.

PLEASE SEND APPLICATIONS TO: Tanana Chief Conference

122 First Avenue, Suite 600

Fairbanks, Alaska 99701

907-452-8251

800-478-6822 in AK

800-478-6822 outside AK

Fax (907) 459-3885

Page 3: 31st Roustabout Training Program...1 31st Roustabout Training Program Offered by: Tanana Chiefs Conference Doyon Drilling, Inc. To be considered for the Roustabout training program,

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Roustabout FAQs

The following are Frequently Asked Questions (FAQs) about Roustabouts with Doyon Drilling, Inc. (DDI).

1. What is a Roustabout?

A roustabout is an entry level position with DDI that performs duties to support rig operations and

maintenance and is accountable to the Roustabout Pusher/Driller.

2. What qualifications are needed to be a roustabout?

Must be a Doyon, Limited shareholder, be 18 years of age or older, be physically capable to perform job

functions, able to pass medical, drug and alcohol screening, and be dependable.

3. What is the salary for those just starting as a roustabout?

The starting wage for a roustabout is $25.80/hour and $38.70 overtime.

4. What are the accommodations while working on the rigs?

Accommodations while working on the rig include full catering; lodging in 1-2 man rooms, and airfare

between Anchorage and your worksite plus return. Employees are responsible for their own travel if

they live outside Anchorage.

5. What does it take to work at DDI?

To work at DDI, employees leave their families for 2 weeks at a time. Because of the time away from

home and the physical demands of the job, it is important for employees to be physically and mentally

strong, support the safety program and be a team player.

6. What are common reasons employees leave DDI?

Common reasons employees leave DDI include missing flights, alcohol and drug related issues, home

and family situations and medical circumstances.

7. Why should I want to work at DDI?

There are many reasons for why DDI is a great place to work. Employees have excellent pay, retirement

and benefits, work half the year, have stability and opportunities for advancement.

8. What are some of the cons of working at DDI?

As with any place of employment, there are downsides that should be considered. At DDI, employees

can expect to be absent from home for extended periods of time, miss special occasions with family and

friends, work monotonous assignments, work long hours in extreme weather conditions and be isolated.

9. Where can I learn more about DDI?

Visit the DDI website at www.doyondrilling.com.

Page 4: 31st Roustabout Training Program...1 31st Roustabout Training Program Offered by: Tanana Chiefs Conference Doyon Drilling, Inc. To be considered for the Roustabout training program,

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JOB DESCRIPTION

JOB TITLE Roustabout LOCATION Remote North Slope

TYPE OF

POSITION

Full Time POINT OF

HIRE

Anchorage, Alaska

SCHEDULE 2 weeks on/2weeks

off HOURS 12 hour shifts

REPORTS TO Roustabout Pusher /

Driller FSLA

STATUS

Non-Exempt

STARTING

PAY

AFTER 90

DAYS

N/A

DATE POSTED DATE

CLOSED

JOB SUMMARY: Entry level Position; Performs duties in support of rig operations and maintenance program.

ESSENTIAL FUNCTIONS: Includes the following, but not limited to:

Clean rig as directed by Roustabout Pusher and Driller

Prepare drill string, tubing and casing for use

Assists drill crew and other support personnel as needed

Participate in emergency drills Perform preventive maintenance and minor repairs on rig equipment

Maintain clear communication with relief, other crew members, roustabout pusher and Driller

Follow DDI and customer operating and reporting procedures

Participate in safety, spill prevention, and pre-job meetings as required

Perform other duties assigned

KNOWLEDGE, SKILLS & ABILITIES:

Have knowledge of, and understand Doyon Drillings Health, Safety and Environmental (HSE) policy

Have knowledge of possible health, safety and environmental impact and state and federal regulatory compliance

requirements associated with oil and gas drilling operations

Have knowledge of Environmental Management System (EMS) operation, key personnel and their functions, and

responsibilities

Have strong oral and written communication skills

Have basic mathematical skills, (addition, subtraction, division and multiplication)

Ability to work as an effective member of a rig crew and promote cohesiveness

Ability to learn, perceive problems or dangers and sense responsiveness

Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions

DOYON’S FAMILY OF COMPANIES Doyon Drilling, Inc.

Human Resources Office

3201 C. Street, Suite 703

Anchorage AK 99503

1-877-DOYON HR

1-877-369-6647

Page 5: 31st Roustabout Training Program...1 31st Roustabout Training Program Offered by: Tanana Chiefs Conference Doyon Drilling, Inc. To be considered for the Roustabout training program,

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QUALIFICATIONS:

High school diploma or equivalent

Valid Drivers License (Preferred)

WORKING ENVIRONMENT: While performing the duties of this job, the employee is frequently exposed to

extreme weather conditions, temperatures reaching as low as 50 degrees below zero during the winter months. Employee

is occasionally exposed to wet and/or humid conditions; moving mechanical parts; high, precarious places, extreme heat

and high noise levels. Employee will work in an environment where there is risk that they will be exposed to toxic, caustic

and/or hazardous chemicals, fumes or airborne particles. Workers are required to wear personal protective equipment

while on the job.

PHYSICAL DEMANDS: An individual will be required to work the majority of hours in a remote industrial

environment, and will need to be able to quickly respond to a change in work demands. Occasional lifting up to (1-50 lbs)

is required. [Reasonable accommodations may be made to enable individuals with disabilities to perform the essential

functions].

PREFERENCE STATEMENT: Preference will be given to Doyon shareholders and Alaska Natives in accordance with Title 43 U.S. Code 1626(g) and

Title 42 U.S. Code 2003-2(i).

REASONABLE ACCOMODATION: It is Doyon’s business philosophy and practice to provide reasonable accommodations, according to applicable state and

federal laws, to all qualified individuals with physical or mental disabilities.

This job description is not an employment agreement or contract. Management has the exclusive right to

alter the scope of work within the framework of this job description at any time without prior notice.

Employee meets essential functions and accepts job responsibilities as outlined in this job description:

Employee Signature Print Name Date

Supervisor/HR Signature has reviewed with employee the job responsibilities as described in this document and

has discussed expected standards of performance.

Job Description Reviewed Date:

Supervisor/HR Signature Print Name Date

Page 6: 31st Roustabout Training Program...1 31st Roustabout Training Program Offered by: Tanana Chiefs Conference Doyon Drilling, Inc. To be considered for the Roustabout training program,

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Tanana Chiefs Conference

& Doyon Drilling, Inc.

Roustabout Training

Application

Tanana Chief Conference

122 First Avenue, Suite 600

Fairbanks, Alaska 99701

907-452-8251

800-478-6822 in AK

800-478-6822 outside AK

Fax (907) 459-3885

Please Type or Print Neatly

INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED!

Last Name:

First Name:

Middle Name:

Date:

Mailing Address:

City: State: Zip Code:

Home Phone Number:

Business Phone Number: Cell or Msg. Number: E-Mail Address:

Have you ever applied for the Roustabout training program before? _____________ Number of times: _______________

If so, briefly state training and/or experience completed since you last applied: __________________________________ _________________________________________________________________________________________________

Have you ever worked for the Doyon Family of Companies? □ Yes □ No

Company Name: Position: Dates Employed:

Why do you want to return to work for the Doyon Family of Companies? ______________________________________

If and are you enrolled into a village or tribal entity that is part of the ANSCA Corporation? □No □Yes if yes please list:

__________________________________________________________________________________________________

Do you have any relatives working for and of the Doyon Family of Companies? □No □Yes if yes please list:

Name of Relative: Relationship: Name of Relative: Relationship: Name of Relative: Relationship:

EDUCATION

High School NAME/LOCATION

FIELD OF STUDY

YRS. COMPLETED

9 10 11 12 GED

DATE GRADUATED / DEGREE

College/University

Vocational

LICENSES Yes NO

1. Do you have any technical licenses? If so, what kind: _________, ___________, __________.

Page 7: 31st Roustabout Training Program...1 31st Roustabout Training Program Offered by: Tanana Chiefs Conference Doyon Drilling, Inc. To be considered for the Roustabout training program,

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EMPLOYMENT HISTORY LIST EMPLOYMENT HISTORY FROM PRESENT TO LAST

RESUME CANNOT REPLACE EMPLOYMENT HISTORY.

INCLUDE ALL PAID OR UNPAID WORK EXPERIENCE AND VOLUNTEER WORK.

LEAVE NO BREAKS IN DATES (PLEASE EXPLAIN)

THIS PAGE MAY BE DUPLICATED IF MORE SPACE IS REQUIRED.

EMPLOYER NAME/COMPANY NAME JOB TITLE DATES

EMPLOYED

ADDRESS

PHONE NUMBER

( )

FROM TO

PRESENT

POSITION DESCRIPTION/VOLUNTEER ACTIVITIES ELIGIBLE FOR REHIRE

yes no

HOURS

PER WEEK PAID

UNPAID

REASON FOR LEAVING

Quit Job Complete Fired Other _________________

*Explain:____________________________________________

Total Length of Employment in this position: Years Months

EMPLOYER NAME/COMPANY NAME JOB TITLE DATES

EMPLOYED

ADDRESS

PHONE NUMBER

( )

FROM TO

POSITION DESCRIPTION/VOLUNTEER ACTIVITIES ELIGIBLE FOR REHIRE

yes no

HOURS

PER WEEK PAID

UNPAID

REASON FOR LEAVING

Quit Job Complete Fired Other _________________

*Explain:____________________________________________

Total Length of Employment in this position: Years Months

EMPLOYER NAME/COMPANY NAME JOB TITLE DATES

EMPLOYED

ADDRESS

PHONE NUMBER

( )

FROM TO

POSITION DESCRIPTION/VOLUNTEER ACTIVITIES ELIGIBLE FOR REHIRE

yes no

HOURS

PER WEEK PAID

UNPAID

REASON FOR LEAVING

Quit Job Complete Fired Other _________________

*Explain:____________________________________________

Total Length of Employment in this position: Years Months

Page 8: 31st Roustabout Training Program...1 31st Roustabout Training Program Offered by: Tanana Chiefs Conference Doyon Drilling, Inc. To be considered for the Roustabout training program,

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CONTINUED - EMPLOYMENT HISTORY

EMPLOYER NAME/COMPANY NAME JOB TITLE DATES

EMPLOYED

ADDRESS

PHONE NUMBER

( )

FROM TO

POSITION DESCRIPTION/VOLUNTEER ACTIVITIES ELIGIBLE FOR REHIRE

yes no

HOURS

PER WEEK PAID

UNPAID

REASON FOR LEAVING

Quit Job Complete Fired Other _____________

*Explain:____________________________________________

Total Length of Employment in this position: Years Months

EMPLOYER NAME/COMPANY NAME JOB TITLE DATES

EMPLOYED

ADDRESS

PHONE NUMBER

( )

FROM TO

POSITION DESCRIPTION/VOLUNTEER ACTIVITIES ELIGIBLE FOR REHIRE

yes no

HOURS

PER WEEK PAID

UNPAID

REASON FOR LEAVING

Quit Job Complete Fired Other _____________

*Explain:____________________________________________

Total Length of Employment in this position: Years Months

EMPLOYER NAME/COMPANY NAME JOB TITLE DATES

EMPLOYED

ADDRESS

PHONE NUMBER

( )

FROM TO

POSITION DESCRIPTION/VOLUNTEER ACTIVITIES ELIGIBLE FOR REHIRE

yes no

HOURS

PER WEEK PAID

UNPAID

REASON FOR LEAVING

Quit Job Complete Fired Other _____________

*Explain:____________________________________________

Total Length of Employment in this position: Years Months

Page 9: 31st Roustabout Training Program...1 31st Roustabout Training Program Offered by: Tanana Chiefs Conference Doyon Drilling, Inc. To be considered for the Roustabout training program,

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CONTINUED - EMPLOYMENT HISTORY

EMPLOYER NAME/COMPANY NAME JOB TITLE DATES

EMPLOYED

ADDRESS

PHONE NUMBER

( )

FROM TO

POSITION DESCRIPTION/VOLUNTEER ACTIVITIES ELIGIBLE FOR REHIRE

yes no

HOURS

PER WEEK PAID

UNPAID

REASON FOR LEAVING

Quit Job Complete Fired Other _____________

*Explain:____________________________________________

Total Length of Employment in this position: Years Months

EMPLOYER NAME/COMPANY NAME JOB TITLE DATES

EMPLOYED

ADDRESS

PHONE NUMBER

( )

FROM TO

POSITION DESCRIPTION/VOLUNTEER ACTIVITIES ELIGIBLE FOR REHIRE

yes no

HOURS

PER WEEK PAID

UNPAID

REASON FOR LEAVING

Quit Job Complete Fired Other _____________

*Explain:____________________________________________

Total Length of Employment in this position: Years Months

EMPLOYER NAME/COMPANY NAME JOB TITLE DATES

EMPLOYED

ADDRESS

PHONE NUMBER

( )

FROM TO

POSITION DESCRIPTION/VOLUNTEER ACTIVITIES ELIGIBLE FOR REHIRE

yes no

HOURS

PER WEEK PAID

UNPAID

REASON FOR LEAVING

Quit Job Complete Fired Other _____________

*Explain:____________________________________________

Total Length of Employment in this position: Years Months

Page 10: 31st Roustabout Training Program...1 31st Roustabout Training Program Offered by: Tanana Chiefs Conference Doyon Drilling, Inc. To be considered for the Roustabout training program,

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The following information is for both paid & unpaid positions,

and MUST correspond with the information given in the

Employment History portion of this application.

TRADES SKILLS/WORK

1. Please check the box and write months/years of experience next to those trades that pertain to you:

___ Electrician ___ Carpenter ___ Plumber ___ Welder

___ Mechanic ___ Ironworker ___ Heavy Equipment Operator

___ Laborer ___ Other___________

2. Please check the level that pertains to you. (If more than one trade, indicate which level goes with each trade):

Journeyman, Certified Apprentice Helper Supervisor

Journeyman, Not Certified

*MACHINERY USAGE/REPAIR

In the space below, please list the type of machinery you have operated and/or repaired and the number of months of experience you

have doing so.

TYPES OF MACHINERY MONTHS OPERATED MONTHS REPAIRED

_________________________________________ ____________________________ ___________________

_________________________________________ ____________________________ ___________________

_________________________________________ ____________________________ ___________________

_________________________________________ ____________________________ ___________________

_________________________________________ ____________________________ ___________________

_________________________________________ ____________________________ ___________________

_________________________________________ ____________________________ ___________________

_________________________________________ ____________________________ ___________________

_________________________________________ ____________________________ ___________________

2. Check the term which most directly describes your mechanical skill level:

Helper Light Duty Heavy Duty Trouble Shooter

*OIL FIELD/NORTH SLOPE/REMOTE CAMP EXPERIENCE

Please list and describe any experience you have working on Alaska’s North Slope or any other type of remote camp. Include oil field

as well as other types of employment.

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Page 11: 31st Roustabout Training Program...1 31st Roustabout Training Program Offered by: Tanana Chiefs Conference Doyon Drilling, Inc. To be considered for the Roustabout training program,

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TRAINING Yes No

1. Any certifications? (We can keep copies in your file)

If so, what kind: ________________, ________________, ______________.

2. Any on-the-job training?

If so, what kind: ________________, ________________, ______________.

3. Any other training pertinent to Roustabout?

If so, what kind: ________________,________________, ______________.

SUPERVISORY EXPERIENCE

1. If you have supervised employees, indicate your responsibilities by checking the appropriate boxes:

Hired or recommended hiring Assigned and reviewed work

Rated work performance Handled disciplinary problems

2. Indicate number of employees and job types supervised: ______________________

3. Percentage of time spent supervising, on average: _____________________________

GENERAL INFORMATION Yes No

1. Have you ever been fired from a job?

If so, why? _____________________________________________________

2. Are there any reasons why you could not participate in work and/or training as scheduled?

3. Where/How did you hear about the current Roustabout recruitment? _______________________________

CONTACTS

1. Please list names of contacts we can use if you are unreachable.

NAME NAME NAME

ADDRESS ADDRESS ADDRESS

CITY/STATE/ZIP CITY/STATE/ZIP CITY/STATE/ZIP

TELEPHONE TELEPHONE TELEPHONE

Page 12: 31st Roustabout Training Program...1 31st Roustabout Training Program Offered by: Tanana Chiefs Conference Doyon Drilling, Inc. To be considered for the Roustabout training program,

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DOYON is looking for HIGHLY MOTIVATED,

CAREER ORIENTED people.

Please give a SUMMARY of your employment goals, including:

A. Please share why you want to be in the Roustabout Program. Discuss you long term employment goals.

B. Is there any reason why you could not work a 2 x 2 schedule (two weeks on and two weeks off)?

C. Use this space to explain any lapses in employment.

CERTIFICATION OF APPLICATION: I hereby certify that all information given on or in connection with this

application is true and complete to the best of my knowledge and belief. I understand that any misrepresentation or

concealment of material fact will be sufficient grounds for rejection of my application and/or removal from the eligible

list and the job databank.

SIGNATURE DATE

Page 13: 31st Roustabout Training Program...1 31st Roustabout Training Program Offered by: Tanana Chiefs Conference Doyon Drilling, Inc. To be considered for the Roustabout training program,

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TANANA CHIEFS CONERENCE

HOUSEHOLD INCOME VERIFICATION

Name:___________________________________________ DOB:____________________________________

I AM A(n): __ Single Parent with dependent(s) (list below)

__ Parent in two-parent family with dependent(s) and spouse (list below)

__ Other, specify __ married __ widowed __ separated __ divorced __ independent

LIST SELF, SPOUSE, AND DEPENDENTS:

Name Tribe Relationship DOB Place of Birth

I AM CURRENTLY:

__ Unemployed, last day worked

__ Employed __full time __ part-time at $ per hour for hours per week. Date Started

Receiving fringe benefits __ yes __ no Receiving health benefits __ yes __ no Last wage per hour

__ Not in labor force. Explain:

FINANCIAL STATEMENT

yes no

1. Are you or a family member receiving ASAP welfare benefits? _____ _____

Per month $ Name of Recipient(s)

2. Are you or a family member receiving Unemployment Benefits? _____ _____

Per week $ Name of Recipient(s)

3. Have you recently moved from your home community to attend training or accept employment? _____ _____

Date moved Name of village, city relocated from

FAMILY INCOME (List GROSS income of all family members, including self):

Name Relationship Source of Income (Do not Include

public asst., unemployment or G.A.)

90 days 6 months 12 months

Total Family Income (90 days)

Total Annualized Income (6 mon. income x2)

Total Family Income (12 mon. actual)

CERTIFICATION: I certify that the information provided is true to the best of my knowledge. I am also aware that the information I

have provided is subject to review and verification and I may have to provide documentation to support this application. I authorize

Tanana Chiefs Conference to verify any and/or all statements made by me in this application with Employment Security; Department

of Health and Social Services; my regional corporation; my village corporation or council; other Employment Assistance, WIA, and

NEW grantees and/or former employers for the purpose of verifying eligibility. I further certify that I have not knowingly and/or

willingly made any misstatement for the purpose of obtaining Employment Assistance, WIA or NEW funds and benefits; and that,

further, I am aware that it is a crime to deliberately and knowingly falsify any application for Federal benefits or State benefits. I am

also aware that I am subject to immediate termination if I am found ineligible after enrollment and may be prosecuted for fraud and/or

perjury if false information was provided on this application. I also have received a copy of the grievance procedure on this date.

*I acknowledge that I understand and agree to the above certification*

Signature of Applicant Date

Page 14: 31st Roustabout Training Program...1 31st Roustabout Training Program Offered by: Tanana Chiefs Conference Doyon Drilling, Inc. To be considered for the Roustabout training program,

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Doyon does conduct background checks. Information provided regarding your background must be accurate and complete. Missing

information could lead to your application being denied AND any future applications for employment will be subject to a minimum

six-month waiting period from date of denial. I understand if I make any material misrepresentation or omit information regarding

my criminal history, I may be subject to immediate discharge regardless of when The Company learns of such matters.

For confidentiality purposes, this page and the following two pages are removed prior to HR sending your application to the hiring

manager. To help ensure that this document is not misplaced, please enter your name below as it is entered on the first page of the

application.

Applicant Name:

Confidential Information Required for Background Check

Social Security Number: - - Date of Birth:

Do you have a valid driver’s license: License Number and State: Class of Driver’s License: Expiration:

No Yes

Has your driver’s license ever been suspended or revoked? No Yes If yes, explain when and why:

Have you ever been convicted of any criminal offense to include misdemeanors AND felonies? You do not

need to list minor traffic violations, but you must list traffic violations that resulted in a criminal conviction.

(A conviction will not necessarily disqualify an applicant from employment.) No Yes

If yes, LIST ALL convictions (misdemeanor, felony or other) and include the following: 1) The type of conviction. 2) The year the conviction occurred. 3) The city and state where the incident occurred.

List all traffic citations received (except parking) within the past three years, including date, place and incident:.

Military Status

Branch of Service Dates Enlisted Present Military Affiliation: Type of Discharge:

None

Active Reserve

Inactive Reserve

While in the military, were you ever charged or convicted of an offense that resulted in a trial by deck court or by

summary, special or general court martial? If yes, give date, place, law enforcing authority or type of court of court

martial, charge and action taken for each incident, using separate sheet to record this information. No Yes

Page 15: 31st Roustabout Training Program...1 31st Roustabout Training Program Offered by: Tanana Chiefs Conference Doyon Drilling, Inc. To be considered for the Roustabout training program,

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Authorization for Release of Information

Except as may otherwise be provided in Doyon’s preference policies, Doyon, Limited & Doyon Family of Companies does not discriminate on the

basis of race, religion, color, national origin, age, physical or mental disability, gender, sexual orientation, marital status, changes in marital status,

pregnancy, parenthood, status as a Vietnam-era or special disabled veteran, or other classifications protected by law.

Doyon, Limited & Doyon Family of Companies conform with Section 403 of Public Law 93-153 and 43 C.F.R. Part 27. Preference will be given to

Doyon shareholders and shareholders of other Alaska Native corporations in accordance with Title 43 U.S. Code 1626(g) and Title 42 U.S. Code

2003-2(i).

Authorization for Release of Information

As part of the employment process, Doyon, Limited & Doyon Family of Companies, hereby known as (“the company”), may obtain a consumer

report and / or Investigative Consumer Report. The Fair Credit Reporting Act as amended by the Consumer Reporting Reform Act of 1996 requires

that we advise you that for the purposes of employment only, a Consumer Report may be made which may include information about your credit

standing, credit capacity, character, general reputation, personal characteristics, or mode of living. Upon written request, additional information as

to the nature and scope of the report, if one is made, will be provided in the event the Report contains information regarding your character, general

reputation, personal characteristics, or mode of living.

During the application process and at any time during any subsequent employment, I herby authorize U.S. Information Search on behalf of The

Company to procure a Consumer Report which I understand may include information regarding my credit worthiness, credit standing, credit

capacity, character, general reputation, personal characteristics, or mode of living. This report may include Criminal Records, Credit reports,

Driving Records, Past Employment or Education Verifications, Worker’s Compensation Claims, and any other source required to verify information

that I have voluntarily supplied. I understand that I may request a complete and accurate disclosure of the nature and scope of the background

verification; to the extent such investigation includes information bearing on my character, general reputation, personal characteristics or mode of

living. I authorize without reservation, any party or agency contacted to furnish the above mentioned information and release all parties involved

from liability and responsibility for doing so. This authorization and consent shall be valid in original, fax, or copy form.

I release The Company from any liability resulting from such an investigation. I certify that all of the information on my application is true and

correct and if I have made any material misrepresentation or omitted information regarding my prior employment, educational, criminal history or

other matters, I am subject to immediate discharge, regardless of when The Company learns of such matters. I understand that employment, if

offered, will be at the will of The Company and myself and may be terminated for any reason by either party. I also understand that the use of

alcohol and illegal drugs is prohibited during employment. I am willing to submit to drug and alcohol testing prior to and during employment.

___________________________________________ ________________________________________

Signature of Applicant Today’s Date

(Signature will be obtained at the time of interview)