Application for Employment

form

Application For Employment

Name:

Address:

Street:

City:

State:

Zip Code:

How Long?:

Personal Information:

Date of Birth:

Social Security Nº:

Hire Date:

Phone Number:

E-mail Address:

Previous three years residency:

Nº1

Street:

City:

State:

Zip Code:

# Years:

Nº2

Street:

City:

State:

Zip Code:

# Years:

Nº3

Street:

City:

State:

Zip Code:

# Years:

If you need more space, please attach a Word or Excel file with the required information.

Attach File:

License Information:

Sect. 383.21 FMCSR states "No person who operates a commercial motor vehicle shall at any time have more than one driver's license". I certify that I do not have more than one motor vehicle license, than that for which information is listed below.

State:

License Nº:

Type:

Expiration Date:

Driving Experience:

Nº1

Class of Equipment:

Type of Equipment:

Dates / From-To:

Number or Miles:

Nº2

Class of Equipment:

Type of Equipment:

Dates / From-To:

Number of Miles:

Nº3

Class of Equipment:

Type of Equipment:

Dates / From-To:

Number of Miles:

If you need more space, please attach a Word or Excel file with the required information.

Attach File:

Accident record for past 3 years or more:

Nº1

Date:

Nature of Accident:

Fatalities:

Injuries

Chemical Spills?

Nº2

Date:

Nature of Accident:

Fatalities:

Injuries:

Chemical Spills?

Nº3

Date:

Nature of Accident:

Fatalities:

Injuries:

Chemical Spills?

If you need more space, please attach a Word or Excel file with the required information.

Attach File:

Traffic convictions and forfeitures for the past 3 years (Other than parking violations):

Nº1

Date Convicted:

Violation:

State / Location:

Penalty:

Nº2

Date Convicted:

Violation:

State / Location:

Penalty:

Nº3

Date Convicted:

Violation:

State / Location:

Penalty:

If you need more space, please attach a Word or Excel file with the required information.

Attach File:

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?

If yes, please explain:

B. Has any license, permit o privilege ever been suspended or revoked?

If yes, please explain:

Employment Record:

Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record).

Must list the complete mailing address: street number and name, city, state and zip code.

Last employer:

Name:

Address:

Phone Number:

Position Held:

From / To:

Salary:

Reason for leaving:

Any gaps in employment and/or unemployment must be explained. Include dates (month/year) and reason:

Where you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?

2nd Last Employer:

Name:

Address:

Phone Number:

Position Held:

From / To:

Salary:

Reason for leaving:

Any gaps in employment and/or unemployment must be explained. Include dates (month/year) and reason:

Where you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?

3rd Last Employer:

Name:

Address:

Phone Number:

Position Held:

From / To:

Salary:

Reason for leaving:

Any gaps in employment and/or unemployment must be explained. Include dates (month/year) and reason:

Where you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?

TO BE READ AND SIGNED BY APPLICANT

I authorize you to make sure investigations and inquiries to my personal, employment, financial or medical history and other related matters as many be necessary in arriving 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.

"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 current/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"

This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge.

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Application for Employment

Application For Employment

Address:

Personal Information:

Previous three years residency:

Nº1

Nº2

Nº3

License Information:

Driving Experience:

Nº1

Nº2

Nº3

Accident record for past 3 years or more:

Nº1

Nº2

Nº3

Traffic convictions and forfeitures for the past 3 years (Other than parking violations):

Nº1

Nº2

Nº3

Employment Record:

Must list the complete mailing address: street number and name, city, state and zip code.

Last employer:

2nd Last Employer:

3rd Last Employer:

TO BE READ AND SIGNED BY APPLICANT

This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge.

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