Application for Employment

Email:

Security number:

Date of birth:

Applicant Name (Last) *

First *

Middle *

Home Phone:

Cell Phone:

Current Address (Street) *

City: *

State: *

Zip Code: *

Position Applying for

Temporary

Part Time

Full Time

Who Referred You?

Rate of Pay Expected?

Are you currently employed?

If not, how long since leaving last employment?

Previous employer?

Dates: (From)

Where?

Rate of Pay

Position

Reason for leaving

Names of any relatives employed by this company

EDUCATION

GENERAL

Have you ever been bonded?

Name of bonding company

(Answer only if a job requirement)

Have you ever been convicted of a felony?

If yes, please explain below. Conviction of a crime is not an automatic bar to employment - all circumstances will be considered.

DRIVER EXPERIENCE AND QUALIFICATIONS

PHYSICAL HISTORY

The Federal Motor Carrier Safety Regulations (49CFR391 Subpart E) requires that all driver applicants pass certain physical tests before they are hired to drive a motor vehicle.

Date of last Department of Transportation prescribed examination

Can you provide a copy

Have you ever been granted a waiver under section 391.49 of the Federal Motor Carrier Safety Regulations pertaining to the loss of foot, leg, hand or arm?YesNo

ALCOHOL AND CONTROLLED SUBSTANCE STATEMENT

The Federal Motor Carrier Safety Regulations 49CFR40.25(j) requires all persons with applying for a driving position requiring a commercial drivers license to answer the following questions:

1) Within the last two years, have you ever tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work?YesNo

12) Within the last two years, have you ever tested positive, or refused to test, on any type of drug or alcohol test administered by an employer for which you preformed safety-sensitive transportation work?YesNo

3) If you answered yes to either 1 or 2 above, can you provide and/or obtain proof that you have successfully completed the DOT return-to-duty requirements?YesNo

Applicants Signature:

Date:

DRIVER’S LICENSE INFORMATION

Driver	State	License Number	Type	Expiration Date
Licenses held
Original issue date of CDL
years must
be shown

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?YesNo

B. Has any license, permit or privilege ever been suspended or revoked?YesNo

C. Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations?YesNo

If you answered “Yes” to A, B, or C, attach a statement giving details.

DRIVING EXPERIENCE

Class of Equipment	Type of Equipment (Van, Tank, Flat, etc.)	Dates From	Dates To	Approximate Total Miles
Straight Truck
Tractor and Semi-Trailer

List states operated in during the last five years:

List special courses or training that will help you as a driver:

List safe driving awards held and who awards were presented by:

Date	Nature of Accident (Head-On, Rear-End, Upset, etc.)	# Fatalities	# Injuries	# Vehicles Towed	Citation Issued?

MOTOR VEHICLE DRIVING RECORD (MVR)

Traffic Convictions and Forfeitures for the past 3 years other than parking violations.

Date	Location	Charge	Penalty

APPLICANT MUST READ AND SIGN

I certify that I have read and understand all of this employment application. It is agreed and understood that the employer or his agents may investigate the applicant’s background to ascertain any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases employers and other persons named herein from all liability for any damages on account of his furnishing such information. I understand that, as an applicant for a position with this company, I may be asked to demonstrate that I am capable of performing tasks that are pertinent to the job.

It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigative Consumer Report, including information regarding my character, personal reputation, personal characteristics and mode of living.

I agree to furnish such additional information and complete such examinations as may be required to complete my employment file.

I also understand that misrepresentation or omission of information or facts may result in my rejection or dismissal.

If hired, I agree to abide by all the rules and policies of the employer.

If you have a (E)-restriction on your license you must apply within 30 days from your hired date, to remove the (E)-restriction from your license to continue employment with our company.

This certifies that I completed this application and that all entries on it and information in it are true and complete to the best of my knowledge.