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 origin, age, marital status, veteran status, non-job related disability, or any other protected group status.
Date of Application:
Position(s) Applied for:
Name
Last First Middle
List your addresses of residency for the past 3 years.
Current Address
Street City
Phone How Long?
State ZipCode
Previous
Addresses
How Long?
Street City
State ZipCode
How Long?
Street City
State ZipCode
How Long?
Street City
State ZipCode
Do you have the legal right to work in the United States?
Are you over the age of 18?
Have you worked for this company before?
Where?
Dates: From To Rate of Pay Position
Reason for leaving
Are you employed? If not, how long since leaving last employment?
Who referred you? Rate of pay expected
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 fully on a seperate sheet of paper. 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 attached job description)?
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 sheet as necessary.)
*Includes vehicles having a GVWR of 26,001 lbs. Or more, vehicles designed to transport 15 or more passengers, or any size
vehicles used to transport hazardous materials in a quantity requiring placarding.
ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED) IF NONE, WRITE NONE
TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)
IF NONE, WRITE NONE
GRADE SCHOOL GRADES COMPLETED
HIGH SCHOOL
COLLEGE
LAST SCHOOL ATTENDED
(NAME) (CITY)
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?
IF THE ANSWER TO EITHER A OR B IS YES, ATTACH STATEMENT GIVING DETAILS
DRIVING EXPERIENCE IF NONE, WRITE NONE
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?
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)
(Required) I 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.
(Required) 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, inquires 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.
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