Name
Social Security No. --
Date of Birth //
List your addresses of residency for the past 3 years
Present Address Telephone No. () -
Previous Address
Have you worked for this company before? NoYes From To Position Reason for leaving
Are you currently employed? YesNo If not, how long since leaving last employment?
Have you been convicted of a crime, excluding misdemeanors and summary offenses? NoYes If yes, describe in full
Who referred you? Can you provide proof of age? YesNo
Do you want to work Full TimePart Time Specific days & hours if part time: If hired, on what date will you be available to start work?
What is the date of your last DOT Physical Examination?
Name & relationship to you Address Phone number
Have you had any accidents in the past three 3 years? NoYes If yes, list them
Have you had any traffic convictions or forfeitures in the past three 3 years (other than parking violations)? NoYes If yes, list them
List all drivers licenses or permits held in the last 3 years
A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle? NoYes
B. Has any license, permit, or privilege ever been suspended or revoked? NoYes
If the answer to either A or B is 'yes', give details
Driving Experience
List state operated in for last five years
Show special courses or or training that will help you as a driver
Which safe driving awards do you hold, and from whom?
You must account for all periods of unemployment in the last five (5) years.List all lost time in excess of 30 days
TO BE READ AND SIGNED BY THE APPLICANT
I understand that this is an application and not a contract or a unilateral offer to enter into a contract of any kind between the undersigned and the employer. The use of this application form does not indicate that there are any positions open and does not in any way obligate this employer.
I understand that employment is conditional upon and I authorize you to make such investigations and inquire of my personal, employment, financial and other legally related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools or persons from any and all liabilities and responding to inquiries in connection with my application.
I hereby certify that all of the information I have given on this application is true and complete and that there are no false statements or omissions contained in my response to the questions in this application. I understand that any false information or omissions whether made or omitted intentionally or written and later discovered, may be cause for refusal to hire me or for immediate dismissal without further notice.
This application is current for only sixty (60) days. At the conclusion of this time, if I have not heard from the Employer and still wish to be considered for employment, it will be necessary for me to fill out a new application.
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.
