You must answer every question. If any question does not apply to you, answer with Not Applicable.

In compliance with local, state, and federal equal employment opportunity laws, qualified applicants are considered for all positions without regard to age, race, color, sex, sexual orientation, marital status, veteran status, ot non-job related disability. Please advise in advance if you need any type of special accommodation to comp;ete this application form or need to take any pre-employment test. 

lf you were at above address less than three years, list your previous address.

(Answering this question in an affirmative answer does not preclude a hiring decision)

Employment History

§391.21 (b)(10) A list of the names and addresses of the applicant's employers during the 3 years preceding the date the application is submitted, together with the dates he/she was employed by, and his/her reason for leaving the employ of, each employer; (b)(11)   For those drivers applying to operate a commercial motor vehicle as defined by Part 383 of this subchapter, a list of the names and addresses of the applicant's employers during the 7 year period preceding the 3 years contained in paragraph (b)(10) of this sectionfor which the applicant was an operator of a commercial motor vehicle, together with the dates of employment and the reasons for leaving such employment.

 

A total of 10 years work history is required. All gaps must be shown  

Current or most recent employer
Next Previous Employer
Next Previous Employer
Next Previous Employer
Next Previous Employer
Next Previous Employer
Previous Employee Pre-employment Drug and Alcohol Testing Statement
Accident record for past 3 years or more
Next Previous
Next Previous
Next Previous
Next Previous
Last Accident
Traffic convictions and license forfeitures for the last 3 years (Other then parking violations)
Traffic conviction or license forfeiture
Traffic conviction or license forfeiture
Traffic conviction or license forfeiture
Drivers License
Driving Experience: (Class of Equipment)
Straight Truck
Tractor Trailer
Other
Education
Last School Attended
Applicant's Statement

In connection with my appîication to the company, l understand that the Fair Credit Reporting Act, Public Law 91-508 8i 104-208 requires that l be advised that routine inquiry may be made during the companys initial or subsequent processing which will provide applicable information concerning character and general reputation. I also understand that investigative background inquiries as required by the Federal Motor Carrier Safety Regulations 391.23 be r'nade on me including PFEViGUS Bmplnyem, along with schools, consumer credit, crimine! convictions. motor vehicle records. and other reports.

These reports will include infomation as to my character. work habits, perfomance, education, compensation, and experience along with reasons for termination of employment from previous employers. Furthermore, I understand that the company may be requesting information from various federal. state, and other agencies which maintain records concerning my past activities relating to my driving, credit, criminal, civil, and other experiences as well as claims involving me in the tiles of insurance companies. I authorize without reservation, any or agency contacted lo furnish the above infomation and release all parties involved from liability and responsibility for doing so. This authorization and consent shall be valid in original, fax, email, other electronic form, or copy form.

I release and agree to hold harmless any individual, company, business institution or government agency from all liability with regard to furnishing infomation to this company. I agree to release and hold harmless this company from all liability with respect to the receipt of such information.

l oertify that this application was only completed by ril-ier and that alt entries on it and the infomation I have furnished on this application form is tme and complete. I authorize you to make such investigations and inquiries of my personal, employment, ñnancial. or medical history. (Generally, inquiries regarding medical history wilt be made onty and if 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 infomation in connection writnrn-y application, ln the event of employment, l understand false or misleading information given in my application or In inrerviewœ) may result in discharge. I understand alsoI that l am required to abide by all rules and regulations ofthe Company if a conditional ofíer of employment is made.

l understand that infomation l provide regarding current andtor previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 391.23. I understand that pursuant to 391.23 l have a right to: Review information provided by current previous employers; have errors in the infomation corrected by previous employers and those previous employers to resend the corrected information tothe prospective employer; and have a rebuttat statement attached to the alleged erroneous information, if the previous employeds) and I cannot agree on the accuracy ofthe intern-tation,