In compliance with Federal and State equal employment opportunities 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.
I authorize you to make such investigations and inquireis of my personal, employment, financial or medial 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 personal 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 previouse 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.
(IF REJECTED SUMMARY REPORT OF REASONS SHOULD BE PLACED IN FILE)
List your addresses for the past 3 years.
Do you have the legal right to work in the United States?YesNo
If yes, please explain fully on a separate sheet of paper. Conviction of a crime is not an automatic bar to employment-all circumstances will be considered
All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3years. 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 withthe most recent. Add another sheet as necessary.)
Were you subject to the FMCRs^ While Employed?YesNo
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?YesNo
*Includes vehicles having 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 the quantity requiring placarding.^The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstatecommerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,0001 pounds or more, (2) isdesigned or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardousmaterials in a quantity requiring placarding.
ACCIDENT RECORD for past 3 years or more (attach sheet if more space is required). If non, write none
TRAFFIC CONVICTIONS and forfeitures for the past 3 years (other than parking violations). If none, write none.
List all driver licenses or permits held in the past 3 years
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?YesNo
B. Has any license, permit or privilege ever bee suspended or revoked?YesNo
DRIVING EXPERIENCE check yes or no
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