Error: Contact form not found. Personal Information First Name * Middle Initial Last Name * Street Address * City * State * Zip Code *(Numbers only) CELL PHONE (FORMAT: 123-456-7890) * Email Address * How did you hear about us? -- Select Position -- Senior Estimator Superintendent Foreman Operator Pipelayer Pipelayer Helper Project Manager Human Resources Dept Project Coordinator Estimator Other If referred, by whom? Distance willing to commute one way? Have you ever been employed by Delta Pipeline? Yes No If yes, list date(s) and job title(s) Do you have any relatives employed by Delta Pipeline? Yes No Are you at least 18 years or older? Yes No If under 18 years old, do you have a work permit? Yes No Available Start Date Desired Pay List 3 persons not related to you who have knowledge of your work performance within the last 5 years. References Name Contact Phone Number (FORMAT: 123-456-7890) Name Contact Phone Number (FORMAT: 123-456-7890) Name Contact Phone Number (FORMAT: 123-456-7890) General If hired, can you provide proof of authorization to work in the United States? Yes No Do you possess a valid driver’s license and auto insurance? Yes No Do you have a reliable form of transportation to and from work? Yes No If hired, are you able to submit to a pre-employment drug screen? Yes No Are you able to work nights, weekends, and overtime as required? Yes No Are you able to perform the essential functions of the job for which you are applying, with or without reasonable accommodation(s)? Yes No May we contact your current employer for references? Yes No May we contact your previous employer(s) for references? Yes No Please Acknowledge Safety Waiver The Undersigned has requested permission to access certain construction site(s) of Delta Pipeline, Inc. The Undersigned agrees and acknowledges that they are aware of ongoing construction activities at the construction site(s). The Undersigned further agrees and acknowledges that construction sites, including the above-referenced site(s), are inherently dangerous environments. This holds true despite the safety precautions taken by Delta Pipeline, Inc., its subcontractors, or other parties performing work at the construction site(s). In consideration of being granted access to the construction site(s), the Undersigned agrees to execute this Waiver of Liability and Release and to be bound by the terms herein. WHEREFORE, the Undersigned, for him/herself and for his/her personal representatives, heirs, next of kin, and assigns, acknowledges and agrees: The Undersigned acknowledges that he/she fully understands that construction and other activities at the Construction Sites are dangerous and involve risks of serious injury, death, and/or property damage. To the fullest extent permitted by law, the Undersigned (and on behalf of the Undersigned’s personal representatives, heirs, next of kin, and assigns) RELEASES, WAIVES AND DISCHARGES, AND COVENANTS NOT TO SUE, Delta Pipeline, Inc., the Construction Site owner, any contractor or subcontractor, or any person engaged by any of them, to perform any work or services at the Construction Site(s), and their officers, directors, stockholders, members, employees, representatives, agents, employees, parents, subsidiaries, sureties, insurance companies, affiliates, partners, joint ventures, attorneys, predecessors, successors, and assigns (collectively, the “Releasees”) from any and all damages, losses, penalties, liabilities, costs, attorney’s fees and expenses of any nature, and any demands, claims, suits, and causes of action therefor, arising out of or resulting from the Undersigned’s presence at the Construction Site(s), including negligence. The Undersigned ASSUMES FULL RESPONSIBILITY FOR, AND RISK OF, INJURY TO HIS/HER PERSON OR HIS DEATH or damage to his/her property, whether caused by the negligence of the Releasees or otherwise, occurring during or as a result of the Undersigned’s presence at the Construction Site(s). To the fullest extent permitted by law, the Undersigned will indemnify, defend, and hold harmless Delta Pipeline, Inc. and all of its officers, directors, stockholders, members, affiliates, parents, subsidiaries, employees, agents, sureties, insurance companies, predecessors, successors and assigns (collectively, the “Indemnities”), from and against any and all allegations, claims, actions, suits, demands, damages, obligations, losses, settlements, judgments, costs, expenses (including, without limitation, attorney’s fees and costs), or liability (the “Losses”) for injuries to property, injuries to persons including death, and from any and all other claims, suits, or liability on account of or arising out of, in whole or in part, of any act or omission of the Undersigned, including negligence. The indemnification and hold harmless obligation hereunder shall not be limited by a limitation on amount or type of damages or compensation. The Undersigned acknowledges that he/she has sole responsibility to evaluate carefully the risks inherent in accessing the Construction Site(s) and that he/she has fully considered those risks, including, without limitation, dangers posed by willful or negligent conduct of himself/herself and/or by others. The Undersigned agrees that he/she will not utilize any tools or operate any equipment unless he/she has the appropriate training, experience, and qualifications to operate such tools or equipment. The Undersigned acknowledges and voluntarily assumes full responsibility for, and full risk of, property damage or loss, or bodily, mental, or personal injury, including death, relating to his/her presence at the Construction Sites or the operation of any tools or equipment. The Undersigned grants and conveys all right, title, and interest in any and all photographic images and video or audio recordings made by Delta Pipeline, Inc. during the Undersigned’s access to the Construction Site(s), including, but not limited to, any royalties, proceeds, or other benefits derived from such photographs or recordings. The Undersigned agrees to be governed by and follow all health, safety, or otherwise applicable rules and regulations of Delta Pipeline, Inc. The Undersigned acknowledges that no person shall be allowed on the site unless accompanied by a duly authorized agent of Delta Pipeline, Inc. The Undersigned agrees that if any portion of this document is held invalid, the remaining provisions shall be binding and continue in full force and effect. I fully understand that by executing this document I am waiving, releasing and giving up potential legal rights. By executing this document, I intend to fully and finally waive all claims I may have against Delta Pipeline, Inc. and further fully and finally release Delta Pipeline, Inc. from any liability arising from my presence on the Construction Site(s), for negligence or otherwise. I have read this Waiver of Liability and Release carefully, understand its significance, voluntarily agree to all of its terms, and sign it of my own free will. PLEASE ACKNOWLEDGE:* Yes, Accepted Please Acknowledge Below I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery. I hereby authorize Delta Pipeline, Inc. to thoroughly investigate my references, work record, education and other matters related to my suitability for employment (excluding criminal background information) unless otherwise specified above. I further authorize the references I have listed to disclose to the company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the Company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure. I understand that nothing contained in the application or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and the Company. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or the Company, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the Company's designated representative. In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire. The Company will consider qualified applicants, including those with criminal histories, in a manner consistent with state and local "Fair Chance" laws. PLEASE ACKNOWLEDGE:* Yes, Accepted No, Not Accepted Submit
