TO BE READ AND SIGNED BY APPLICANT
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1 6300 South 45 th West, Idaho Falls, ID Ph: Direct Ph/Fax: or DRIVER S APPLICATION FOR EMPLOYMENT Applicant Name Date of Application (print) 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 origin, age, marital status, veteran status, non-job related disability, or any other protected group status. TO BE READ AND SIGNED BY APPLICANT 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 person 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 (b) and (e). I understand that I have the right to: Review information provided by previous employers; Have errors in the information corrected 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. Signature Date FOR COMPANY USE PROCESS RECORD APPLICANT HIRED REJECTED EMPLOYED POINT EMPLOYED DEPARTMENT CLASSIFICATION (IF REJECTED, SUMMARY REPORT SHOULD BE PLACED IN FLLE) SIGNATURE OF INTERVIEWING OFFICER TERMINATION OF EMPLOYMENT TERMINATED DEPARTMENT RELEASED FORM DISMSSED VOLUNTARILY QUIT OTHER TERMINATION REPORT PLACED IN FILE SUPERVISOR
2 APPLICANT TO COMPLETE (answer all questions please print) Position(s) Applied for Name Social Security No. Last First Middle List your addresses of residency for the past 3 years. Current Address Street City Phone How Long? State Zip Code yr/mo. Address: Previous Addresses How Long? Street City State & Zip Code yr/mo. How Long? Street City State & Zip Code yr/mo. How Long? Street City State & Zip Code yr/mo. Do you have the legal right to work in the United States? Date of Birth / / Can you provide proof of age? (Required for Commercial Drivers) Have you worked for this company before? Where Dates: From To Rate of Pay Position Reason for leaving Are you now employed? If not, how long since leaving last employment? Who referred you? Rate of pay expected Have you ever been bonded? Name of bonding company (Answer only if a job requirement) Have you ever been convicted of a felony? If yes, please explain fully on a separate sheet of paper. Conviction of a crime is not an automatic bar to employment-all circumstance will be considered. Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the attached job description)? If yes, explain if you wish.
3 EMPLOYMENT HISTORY All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street numbers, 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 with the most recent. Add another sheet as necessary.) *Includes vehicles having a 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 a quantity requiring placarding. The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous material in a quantity requiring placarding.
4 EMPLOYMENT HISTORY (continued) *Includes vehicles having a 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 a quantity requiring placarding. The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous material in a quantity requiring placarding. ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE IS NEEDED) IF NONE, WRITE NONE
5 S LAST ACCIDENT NEXT PREVIOUS NEXT PREVIOUS NATURE OF ACCIDENT (HEAD-ON, REAR-END, UPSET, ETC.) FATALITIES INJURIES HAZARDOUS MATERIAL SPILL TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE LOCATION CHANGE PENALITY (ATTACH SHEET IF MORE SPACE IS NEEDED) EXPERIENCE AND QUALIFICATIONS DRIVER List all driver licenses or permits held in the past 3 years STATE LICENSE NO. TYPE EXPIRATION DRIVER LICENSES 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 IF THE ANSWER TO EITHER A OR B IS YES, GIVE DETAILS DRIVER EXPERIENCE CHECK YES OR NO CLASS OF EQUIPMENT CIRCLE TYPE OF EQUIPMENT FROM (m/y) STRAIGHT TRUCK TRACTOR AND SEMI-TRAILER NO YES (VAN, TANK, FLAT, DUMP, REFER) NO YES (VAN, TANK, FLAT, DUMP, REFER) TO (m/y) APPROX. NO. OF MILES (TOTAL) TRACTOR TWO TRAILERS NO YES (VAN, TANK, FLAT, DUMP, REFER) TRACTOR THREE TRAILERS MOTORCOACH SCHOOL BUS MOTORCOACH - SCHOOL BUS NO YES (VAN, TANK, FLAT, DUMP, REFER) NO More than 8 YES passengers NO More than 15 YES passengers OTHER LIST STATES OPERATED IN FOR 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? EXPERIENCE AND QUALIFICATIONS OTHER SHOW ANY TRUCKING, TRANPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY LIST COURSES AND TRAINING THAN SHOWN ELSEWHERE IN THIS APPLICATION LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN) EDUCATION CIRCLE HIGHEST GRADE COMPLETED: HIGH SCHOOL: COLLEGE: LAST SCHOOL ATTENDED () (CITY, STATE) TO BE READ AND SIGNED BY APPLICANT This certifies the 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. Signature: Date:
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