Employment Application Applicant Name * Date of Application * In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national organ, age, marital status, veteran status, non-job related disability, or any other protected group status. TO BE READ AND SIGNED BY APPLICANT I authorize you to make such investigations and inquiries of my personal, employment, financial, or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interview’s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company. I understand that information I provide regarding current and/or previous employers may be used, and those employer’s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to: * Review information provided by previous employer; * Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and * Have a rebuttal statement attached to the alleged erroneous information, if the previous employer’s) and I cannot agree on the accuracy of the information. Signature * Clear Date APPLICANT TO COMPLETE Answer all questions Position(s) Applied for * Name * List your address of residency for the past 3 years List current address first. Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal How Long * plus1 Add minus1 Remove Do you have the legal right to work in the United States? * Yes No Date of Birth * (Required for Commercial Drivers) Can you provide proof of age? * Yes No Have you worked for this company before? * Yes No Where? Dates: From To Rate of pay Position Reason for leaving Are you now employed? * Yes No If not, how long since leaving last employment? Who referred you? Rate of pay expected * Have you ever been convicted of a felony? * Yes No If yes, please explain fully. Conviction of a crime is not an automatic bar to employment-all circumstances will be considered. Is there any reason you might be unable to perform the functions of the job for which you have applied. * Yes No If yes, explain if you wish. EMPLOYMENT HISTORY All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state and zip code. Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years’ information on those employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent. Add another as necessary.) Employer Name Address Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Date: From To Position Held Salary/Wage Reason for leaving Contact Person Phone Number Were you subject to the FMCSRs – While Employed? Yes No Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49 DFR part 40? Yes No plus1 Add minus1 Remove Accident Record Accident Record for past 3 years or more. List most recent first. (add more as needed) if none, write NONE Date Nature of Accident Fatalities Injuries Hazardous Material Spill plus1 Add minus1 Remove Traffic Convictions and Forfeitures for the past 3 years (other than parking violations) if none, write NONE Location Date Charge Penalty plus1 Add minus1 Remove A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? * Yes No B. Has any license, permit or privilege ever been suspended or revoked? * Yes No IF THE ANSWER TO EITHER A OR B IS YES, GIVE DETAILS Experience and Qualifications – Driver Driver licenses or permits held in the past 3 years State License No Class Endorsement’s Expiration Date plus1 Add minus1 Remove List states operated in for last five years: Education Highest Grade Completed: * Last School Attended:(Name) * City/State * To be Read and Signed by Applicant This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge. Signature * Clear Date * Submit Application If you are human, leave this field blank.
