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PRE-EMPLOYMENT 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 Mi e Area Co e

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

/Month

/Month

Third Choice Position Applied for _______________________________________ Salary Desired /MonthDate and Notice period of joining a new firm ____________________________________________________Have you ever applied before? Yes No

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EDUCATION

Name, Address and Location Dates Graduate? Course Studied

High SchoolYes No

Diploma:College From: Degree:

To: Yes NoOther From:

Yes No

Diploma:

To:

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

NoHave you ever served in the military? YesService Branch_________________________________________________ Date Entered ______________________________________Date Separated ________________________________________________ Final Rank _________________________________________

Are you a member of a reserve organization? Yes No

HEALTH

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

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WORK HISTORY

List names of employers in consecutive order with present or last employer listed first. Account for allperiods of time including military service and any periods of unemployment. If selfemployed, give firmname and supply business references.PLEASE GIVE MONTH AND YEAR.

Name Of Employer

Name and Title of Last

Dates Employed

Annual Pay

Complete Address Including Zip Code

Supervisor From: To: Starting

Month Month $____________

Telephone Including Area Code Nature of Business EndingYear Year

( ) ___________ ___________ $___________Title Reason for Leaving May we contact?

Duties Yes NoName Of Employer Name and Title of Last Dates Employed Annual Pay

Complete Address Including Zip Code

Supervisor From: To: Starting

Month Month $____________

Telephone Including Area Code Nature of Business EndingYear Year

( ) ___________ ___________ $___________Title Reason for Leaving May we contact?

Duties Yes NoName Of Employer Name and Title of Last Dates Employed Annual Pay

Complete Address Including Zip Code

Supervisor From: To: Starting

Month Month $____________

Telephone Including Area Code Nature of Business EndingYear Year

( ) ___________ ___________ $___________Title Reason for Leaving May we contact?

Duties Yes NoName Of Employer Name and Title of Last Dates Employed Annual Pay

Complete Address Including Zip Code

Supervisor From: To: Starting

Month Month $____________

Telephone Including Area Code Nature of Business EndingYear Year

( ) ___________ ___________ $___________Title Reason for Leaving May we contact?

Duties

Yes No

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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 areapplying for with accommodation? (Ask to see job description if one is notprovided.)

Have you ever been convicted of any crime? (Excluding convictions for marijuanarelated offenses for personal use more than two years old, convictions that have

been sealed, expunged or legally eradicated, or misdemeanors for whichprobation was completed and the case was dismissed by court.) Note:A Yesresponse does not automatically disqualify your application. If Yes, please attach

explanation.

Are you currently out on bail or released on your own recognizance pendingtrial? 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 toresearch my qualifications for this position. I hereby give my consent to any former employer to provide employment-relatedinformation about me to the Company and will hold the Company and my former employer harmless from any claim made onthe 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 interviewprocess 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