Employment Application

Employment 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.

APPLICANT TO COMPLETE

Answer all questions

List your address of residency for the past 3 years

List current address first.
Address *
Address
City
State/Province
Zip/Postal
Do you have the legal right to work in the United States? *
(Required for Commercial Drivers)
Can you provide proof of age? *
Have you worked for this company before? *
Are you now employed? *
Have you ever been convicted of a felony? *
Is there any reason you might be unable to perform the functions of the job for which you have applied. *

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

Address
Address
City
State/Province
Zip/Postal
Country
Were you subject to the FMCSRs – While Employed?
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?

Accident Record

Accident Record for past 3 years or more. List most recent first. (add more as needed) if none, write NONE

Traffic Convictions

and Forfeitures for the past 3 years (other than parking violations) if none, write NONE
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? *
B. Has any license, permit or privilege ever been suspended or revoked? *

Experience and Qualifications – Driver

Driver licenses or permits held in the past 3 years

Education

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.