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Professional References

Please list those we may contact who can verify your academic and/or work history.

Name

City/State

Phone

Relationship

Education

Circle the highest grade completed:

High School 9 10 11 12

1

College 234

Graduate

Ph.D.

123

1

School Name and Location

Degree or Certificate Received

Did you Graduate?

Yes or No (if no, please list credit hours earned)

Major Subject

High School or GED

College or University

Graduate

Other

Please list any other special training, skills, licenses, certifications, and experience relevant to the position for which you are applying:

Please list any job-related professional or trade group affiliations:

Military Service

Branch:

From

To

_________________________________________________

____________________

_____________________

Did you obtain any specialized skills or abilities as a result of service in the military?

  • Yes

  • No

If so, please describe: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

__________________________________________________________________________________________________________ ____

Are you an active member of the National Guard or Reserves?

  • Yes

  • No

2011 Maxum Petroleum, Inc.

500 River East Drive | Belle, WV 25015 | (304) 926-3002 | www.maxumpetroleum.com

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