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 Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal How Long * Add 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 Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe 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 Add 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 Add Remove Traffic Convictions and Forfeitures for the past 3 years (other than parking violations) if none, write NONE Location Date Charge Penalty Add 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 Add 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
