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Employment Application

Step 1 of 5 - Current Contact Information

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 original, age, marital status, veteran status, non-job related disability, or any other protected group status.

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 I have 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 prosepctive employer; and
- Have a rebuttal statement attached to the alleged erreoneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.
Applicant Name*
First Middle Last
Home Phone*
Cell Phone
Email*
Current Address
Street Address Address Line 2 City State ZIP Code
Position(s) Applied for*
List your addresses of residency for the past 3 years.

Previous Address*

Use '+' to add more than one

Street Address	City	State

Do you have the legal right to work in the United States?
Date of Birth*
Can you provide proof of age?
Have you worked for this company before?
Where?
Begin Date
End Date
Rate of Pay
Position
Reason for leaving
Are you now employed?
No? How long since last employment?
Who referred you?
Rate of pay expected
Have you ever been bonded?
Name of bonding company
Have you ever been convicted of a felony?
If yes, please explain
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?
If yes, explain if you wish:

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Employment History

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceeding 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 a vehicle.

Note: List employers in reverse order starting with the most recent.
Company Name
Company Address
Street Address Address Line 2 City State ZIP Code
Contact Person
Phone Number
From Date
To Date
Position Held
Salary/Wage
Reason for leaving
Were you subject to the FMCSRs+ while employed?
Was your job designated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
Add a 2nd Employment History?
- Yes
Company Name
Company Address
Street Address Address Line 2 City State ZIP Code
Contact Person
Phone Number
From Date
To Date
Position Held
Salary/Wage
Reason for leaving
Were you subject to the FMCSRs+ while employed?
Was your job designated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
Add a 3rd Employment History?
- Yes
Company Name
Company Address
Street Address Address Line 2 City State ZIP Code
Contact Person
Phone Number
From Date
To Date
Position Held
Salary/Wage
Reason for leaving
Were you subject to the FMCSRs+ while employed?
Was your job designated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
Add a 4th Employment History?
- Yes
Company Name
Company Address
Street Address Address Line 2 City State ZIP Code
Contact Person
Phone Number
From Date
To Date
Position Held
Salary/Wage
Reason for leaving
Were you subject to the FMCSRs+ while employed?
Was your job designated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

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Driving History

* Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers, 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 vehiclee on a highway in 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 8 or more 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.
Last

List Please

Use '+' to add more than one. Nature of Accident = Head-On, Rear-End, Upset, etc.

Dates	Nature of Accident	Fatalities	Injuries	Hazardous Material Spill

Traffic Convictions and Forfeitures for the past 3 years (other than parking violations).

List Please

Use '+' to add more than one

Location	Date	Charge	Penalty

Experience and Qualifications - Driver

List all driver licenses or permits held in the past 3 years.

List Please

Use '+' to add more than one

State	License No.	Type	Expiration Date

A. Have you ever been denied a license permit, or priviledge to operate a motor vehicle?
B. Has any license, permit, or priviledge ever been suspended or revoked?
If the answer to either A or B is Yes, give details:
Driving Experience
Straight Truck
Type of Equipment
From Date
To Date
Approx. No. of Miles
Tractor and Semi-Trailer
Type of Equipment
From Date
To Date
Approx. No. of Miles
Tractor and Two Trailers
Type of Equipment
From Date
To Date
Approx. No. of Miles
Tractor and Three Trailers
Type of Equipment
From Date
To Date
Approx. No. of Miles
Motorcoach - School Bus (more than 16 passengers)
From Date
To Date
Approx. No. of Miles
Motorcoach - School Bus (more than 8 passengers)
From Date
To Date
Approx. No. of Miles
Other?
- Other Driving Experience not Listed?
Type of Equipment
From Date
To Date
Approx. No. of Miles
List states operated in for the 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?

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Careers

Employment Application

Step 1 of 5 - Current Contact Information

Employment History

Driving History

Experience and Qualifications - Driver

Experience and Qualifications - Other

Education