APPLICATION FOR EMPLOYMENT

Applicant Name:
Company:
Address:
City: State: Zip Code:

 

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 employers;
  • 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.

Check this box to acknowledge you have read and agree to the above statement. Date:

 

APPLICANT TO COMPLETE

(answer all questions)

Position(s) Applied for:
Last Name: First Name: Middle:
Social Security Number: (for security reasons we do not accept this via our online application process)

Current Address:

Street: City:
State: Zip Code: Phone:

Previous Addresses:

Street: City:
State: Zip Code: Phone: How long did you live at this address? years months

Street: City:
State: Zip Code: Phone: How long did you live at this address? years months

Street: City:
State: Zip Code: Phone: How long did you live at this address? years months

Street: City:
State: Zip Code: Phone: How long did you live at this address? years months

Do you have the legal right to work in the United States? Yes No
Date of Birth:
  (month) (day) (year)
(Required for Commercial Drivers)
Can you provide proof of age?
  YES NO
Have you worked for this company before?  
YES NO  

If you answered Yes to the above section please complete the items below, if you answered No you can skip to the next section.

 

Where did you work?
Dates:  
From:
  (month) (day) (year)
To:
  (month) (day) (year)
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 bonded?
(Answer only if a job requirement) YES NO
Name of bonding company:
Have you ever been convicted of a felony?  
YES NO  

If yes, please explain fully in the text box below. 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 [as described in the job description]?  
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.

EMPLOYER DATE
NAME:
FROM
  MO. YR.
TO
  MO. YR.
ADDRESS: POSITION HELD:
CITY STATE ZIP
SALARY/WAGE:
CONTACT PERSON PHONE NUMBER
REASON FOR LEAVING:
WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED? YES NO
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-RELATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? YES NO
EMPLOYER DATE
NAME:
FROM
  MO. YR.
TO
  MO. YR.
ADDRESS: POSITION HELD:
CITY STATE ZIP
SALARY/WAGE:
CONTACT PERSON PHONE NUMBER
REASON FOR LEAVING:
WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED? YES NO
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-RELATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? YES NO
EMPLOYER DATE
NAME:
FROM
  MO. YR.
TO
  MO. YR.
ADDRESS: POSITION HELD:
CITY STATE ZIP
SALARY/WAGE:
CONTACT PERSON PHONE NUMBER
REASON FOR LEAVING:
WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED? YES NO
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-RELATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? YES NO
EMPLOYER DATE
NAME:
FROM
  MO. YR.
TO
  MO. YR.
ADDRESS: POSITION HELD:
CITY STATE ZIP
SALARY/WAGE:
CONTACT PERSON PHONE NUMBER
REASON FOR LEAVING:
WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED? YES NO
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-RELATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? YES NO
EMPLOYER DATE
NAME:
FROM
  MO. YR.
TO
  MO. YR.
ADDRESS: POSITION HELD:
CITY STATE ZIP
SALARY/WAGE:
CONTACT PERSON PHONE NUMBER
REASON FOR LEAVING:
WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED? YES NO
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-RELATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? YES NO
EMPLOYER DATE
NAME:
FROM
  MO. YR.
TO
  MO. YR.
ADDRESS: POSITION HELD:
CITY STATE ZIP
SALARY/WAGE:
CONTACT PERSON PHONE NUMBER
REASON FOR LEAVING:
WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED? YES NO
WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-RELATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? YES NO

* Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

† The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway ni interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (IF NONE, WRITE NONE)
  DATES NATURE OF ACCIDENT
(HEAD-ON, REAR-END, UPSET, ETC.)
FATALITIES INJURIES HAZARDOUS MATERIAL SPILL
LAST ACCIDENT
NEXT PREVIOUS
NEXT PREVIOUS
TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE
LOCATION DATE CHARGE PENALTY
EXPERIENCE AND QUALIFICATIONS - DRIVER
Driver licenses or permits held in the past 3 years STATE LICENSE NO. CLASS ENDORSEMENTS EXPIRATION DATE
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:
DRIVING EXPERIENCE CHECK YES OR NO
CLASS OF EQUIPMENT SELECT TYPE OF EQUIPMENT DATES APPROX. NO. OF MILES
(TOTAL)
FROM (M/Y) TO (M/Y)
STRAIGHT TRUCK YES NO
VAN TANK FLAT DUMP REFER
TRACTOR AND SEMI-TRAILER YES NO
VAN TANK FLAT DUMP REFER
TRACTOR - TWO TRAILERS YES NO
VAN TANK FLAT DUMP REFER
TRACTOR - THREE TRAILERS YES NO
VAN TANK FLAT DUMP REFER
MOTORCOACH - SCHOOL BUS YES NO
(more than 8 passengers)
------
MOTORCOACH - SCHOOL BUS YES NO
(more than 15 passengers)
------
OTHER ------
LIST STATES OPERATED IN FOR LAST FIVE YEARS:
SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER:
WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM?
EXPERIENCE AND QUALIFICATIONS - OTHER
SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY:
LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION:
LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN):
EDUCATION
SELECT HIGHEST GRADE COMPLETED:
1 2 3 4 5 6 7 8
HIGH SCHOOL:
1 2 3 4
COLLEGE:
1 2 3 4
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.
In lieu of a signature, check this box to acknowledge the above statement: I CERTIFY THIS APPLICATION WAS COMPLETED BY ME
Enter Your Email Address: