Application for Employment
Applicant's Initials: Date:
Full Name: Telephone:
Current Address: City: State:
Zip Code: E-mail:  
* If at the above residence for less than three years, list below all residencies for the past three years.
Address: City: State:
Zip Code:  
Address: City: State:
Zip Code:        
Position applying for:
Temp:
Part Time:
Full Time:
Who referred you? Rate of pay expected?
Have you worked for this company before?
Yes No
Dates:
From:
To:
Where? Rate of pay: Position:
Reason for leaving?
Names of any relatives employed by this company:
Are you currently employed? Yes No If not how long since leaving last employment?
Education
Select highest grade completed: 1 2 3 4 5 6 7 8 9 10 11 12 College: 1 2 3 4
Last school attended: Address:
General
Have you ever been bonded? Yes No Bonding company:
(answer only if a job requirement)
Have you ever been convicted of a felony?: Yes No

If yes, explain fully. (Conviction of a crime is not an automatic bar to employment. All circumstances will be considered.)
 

Experience & Qualification
Date of Birth: The US Department of Transportation requires that driver applicants state date of birth.
Social Security No.

Answer the questions in this section only if applying for driver position

Drivers Licenses held in the past 3 years must be shown
State
License Number
Class
Endorsements
Exp. Date
A.
 Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No
B.
 Has any license, permit or privilege ever been suspended or revoked? Yes No
C.
 Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations? Yes No
If you answered yes to A, B, or C. Give details:
D. Have you ever tested positive or refused a DOT drug or alcohol pre-employment test within the past two years from an employer who did not hire you? Yes No :
Driving Experience
Class of Equipment
Type of Equipment
Dates
Approximate total miles
Straight Truck
to
Tractor & Semi trailer
to
Twin Trailers-LCV's
to
Other
to
List states operated in during the last five years:
List driving awards held and who awards were presented by:
Accident Review for last 3 years
Have you had any accidents in the past 3 years?   Yes  No   If yes, please fill out the information below:
Dates
Nature of accident
Fatalities
Injuries
Last accident
Yes No
Yes No
Next Previous
Yes No
Yes No
Next Previous
Yes No
Yes No
Traffic Convictions and Forfeitures for the past 3 years other than parking violations
Have you had any traffic convictions or forfeitures in the past 3 years (other than parking violations)?    Yes   No    If yes, please fill out the information below:
Location
Date
Charge
Penalty
Employment Record
The US Department of Transportation requires that driver applications show all employment for the last three years, and  must also show commercial driver employment for seven years immediately preceding this three year period for a total of 10 years driving employment.
Start with last or current position, including military Experience, and work back.

Company:
Full Address:
Zip:
Position Held:
Reason for leaving:
Supervisor Name:
City: State:
Phone
From: To: Salary:

Company:
Full Address:
Zip:
Position Held:
Reason for leaving:
Supervisor Name:
City: State:
Phone
From: To: Salary:

Company:
Full Address:
Zip:
Position Held:
Reason for leaving:
Supervisor Name:
City: State:
Phone
From: To: Salary:

Company:
Full Address:
Zip:
Position Held:
Reason for leaving:
Supervisor Name:
City: State:
Phone
From: To: Salary:

Company:
Full Address:
Zip:
Position Held:
Reason for leaving:
Supervisor Name:
City: State:
Phone
From: To: Salary:

Company:
Full Address:
Zip:
Position Held:
Reason for leaving:
Supervisor Name:
City: State:
Phone
From: To: Salary:

Company:
Full Address:
Zip:
Position Held:
Reason for leaving:
Supervisor Name:
City: State:
Phone
From: To: Salary:

Company:
Full Address:
Zip:
Position Held:
Reason for leaving:
Supervisor Name:
City: State:
Phone
From: To: Salary:

Company:
Full Address:
Zip:
Position Held:
Reason for leaving:
Supervisor Name:
City: State:
Phone
From: To: Salary:

Company:
Full Address:
Zip:
Position Held:
Reason for leaving:
Supervisor Name:
City: State:
Phone
From: To: Salary:
Job Function
Training and Experience
Formal Training
Years of Experience
Area
Formal Training
Years of Experience
Driving line components
Body Work
Diesel Engine tune-up and rebuild
Electrical Repair
Gas Engine tune-up and rebuild
Frame and Wheel Alignment
Tire Service and rebuild
Brakes
Trailer Repair
Cooling System
Air Conditioning (Cab)
Inspection (State/Federal)
Refrigeration (Cargo)
General Car Repair

Shop Equipment
Training and Experience
Formal Training
Years of Experience
Area
Formal Training
Years of Experience
Diagnostic Equipment
Wheel and Tire balancing
Sheet metal equipment
Tire recapping
Frame and axle straightening equipment
Engine Dynamometer
Engine rebuilding
Chassis Dynamometer
Diesel injection equipment
Magnetic Crack Detector
Electric Welder
Engine Analyzer
Oxyacetylene Welder
Noise Measuring Equipment
Paint spray gun
Emissions/Smoke Testing
      ASE Certification(s) (Specify)  
Clerical Experience & Qualifications
Training and Experience
Formal Training
Years of Experience
Area
Formal Training
Years of Experience
Typing
Dictation Machine
Short Hand
Bookkeeping machine
Billing
Switchboard
Filing
Tabular
Computers
Accounting
Word Processing
OS & D
Key Punch
Interline
Calculator
Claims
Adding Machine
Cashier
Telecopier

Dispatcher
Photo Copier
Rates (Indicate tariffs with which you have worked)
Platform Experience & Qualifications
List types of platform experience and number of years of each:
List platform equipment you can operate(list truck, etc.):
List courses or training in platform work:
Applicant must read and Agree to:

I certify that I have read and understood all of this employment application. It is agreed and understood that the employer or his agents may investigate my background to ascertain any and all information of concern to my employment history, whether same is of record or not, and I release employers and other persons named herein from all liability for any damages on account of furnishing such information. I understand that, as an applicant for a position with this company, I may be asked to demonstrate that I am capable of performing t tasks which are pertinent to the job. I also understand that if offered a job, it may be conditioned on the results of a physical examination and drug test.

I further certify that I am a genuine applicant for employment and this application is being submitted solely for the purpose of seeking employment with the employer and for no other reason.

It is also agreed and understood that under the Fair Credit Reporting Act , Public Law 91-508, I have been told that this investigation may include an investigative Consumer Report, including information regarding my character, general reputation , personal characteristics, and mode of living.

I agree to furnish such additional information and complete such examinations as may be required to complete my employment file.

I also understand that misrepresentation or omission of information or facts may result in my rejection or dismissal.

If hired, I agree to abide by all the rules and policies of the employer.

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.
Date:
I agree to the above statement: