Date
*
MM
DD
YYYY
Applicant's Name
*
First Name
Last Name
Company
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Applicants Phone
*
(###)
###
####
Emergency Contact Phone Number
*
Emergency Contact Name
*
First Name
Last Name
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 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 work history, including 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 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.
First Name
Last Name
Position Applying For:
*
Applicant's Name
Current Address
*
List your current address of residency for the past 3 years.
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Previous Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
How Long (yrs./mo)
Previous Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
How Long (yrs./mo)
Previous Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
How Long (yrs./mo)
How were you referred to us?
*
Do you have the legal right to work in the United States?
*
Type of Employment
*
Full-Time
Part-Time
Temporary
Date you will be able to start work.
*
MM
DD
YYYY
Have you worked for this company before?
*
Yes
No
Dates of CSD Employment before:
Rate of Pay, Position and Reason for Leaving CSD
Were you referred to CSD?
*
Yes
No
Rate of pay expected
Are you able to meet the attendance requirements?
*
Do you have any objection to working overtime if necessary?
*
Can you travel if required by this position?
*
Have you ever been previously employed by our organization?
*
Can you submit proof of legal employment authorization and identity?
*
If you are under 18, can you furnish a work permit if it is required?
*
Have you ever been convicted of a crime in the last 7 years?
*
If yes, please explain (a conviction will not automatically bar employment):
Drivers License number (if driving is an essential job duty):
*
Are you now employed?
*
Yes
No
Employer 1:
*
Position Held:
*
Employer 1 Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Employer 1 Phone Number
*
(###)
###
####
Immediate Supervisor's Name and Title:
*
Dates Employed (Start Date to End Date):
*
Beginning Salary:
*
End Salary:
*
Can we contact this employer?
*
If marked no explain why:
Job Summary:
*
Reason for Leaving:
*
Were you subject to the FMCSR’s while employed?
Yes
No
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?
Yes
No
Employer 2:
*
Position Held:
*
Employer 2 Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Employer 2 Phone Number
*
(###)
###
####
Immediate Supervisor's Name and Title:
*
Dates Employed (Start Date to End Date):
*
Beginning Salary:
*
End Salary:
*
Can we contact this employer?
*
If marked no explain why?
Job Summary:
*
Reason for Leaving:
*
Were you subject to the FMCSR’s while employed?
Yes
No
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?
Yes
No
Employer 3
Position Held:
Employer 3 Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Employer 3 Phone Number
(###)
###
####
Immediate Supervisor's Name and Title:
Dates Employed (Start Date to End Date):
Beginning Salary:
End Salary:
Can we contact this employer?
If marked no explain why?
Job Summary:
Reason for Leaving:
Were you subject to the FMCSR’s while employed?
Yes
No
Were you subject to the FMCSR’s while employed?
Yes
No
Employer 4
Position Held:
Employer 4 Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Employer 4 Phone Number
(###)
###
####
Immediate Supervisor's Name and Title:
Dates Employed (Start Date to End Date):
Beginning Salary:
End Salary:
Can we contact this employer?
If marked no explain why?
Job Summary:
Reason for Leaving:
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?
Yes
No
Were you subject to the FMCSR’s while employed?
Yes
No
Explain any Gaps in Employment:
Other Skills and Qualifications:
Summarize any job-related training, skills, licenses, certificates, and/or other qualifications:
Accident 1
*
Date, Nature of Accident, Fatalities, Injuries, Hazardous Material Spill
Accident 2
Date, Nature of Accident, Fatalities, Injuries, Hazardous Material Spill
Accident 3
Date, Nature of Accident, Fatalities, Injuries, Hazardous Material Spill
Traffic Convictions 1
*
Location, Date, Charge, Penalty
Traffic Convictions 2
Location, Date, Charge, Penalty
Traffic Convictions 3
Location, Date, Charge, Penalty
Driver Licenses
State, License No., Type, Expiration Date
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
*
Yes
No
Has any license, permit or privilege ever been suspended or revoked?
*
Yes
No
Straight Truck
*
Tractor and Semi Trailer
*
Tractor - Two Trailers
*
Tractor - Three Trailers
*
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?
Show any trucking, transportation, or other experience that may help in your work for this company.
List courses and training other than shown elsewhere in this application
List special equipment or technical materials you can work with (other than those already shown)
High School
*
Name of School and Location
Did you graduate High School?
Yes
No
College
Name of School, Location, Year Completed, Course of Study, Degree Earned
Technical Training
Name of School, Location, Year Completed, Course of Study, Degree Earned
Other
Reference 1
*
First Name
Last Name
Reference 1 Phone Number
*
Number of Years Known
*
Reference 2
*
First Name
Last Name
Reference 2 Phone Number
*
Number of Years Known
*
Reference 3
*
First Name
Last Name
Reference 3 Phone Number
*
Number of Years Known
*
Applicant Signature:
*
This certifies that this application was completed by me, and that all entries on it and information in it are true and completed to the best of my knowledge.
We are an equal opportunity employer and do not unlawfully discriminate in employment. No question on this application is used for the purpose of limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state or federal law. Equal access to employment, services, and programs is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the organization.
If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either I or the employer can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law.
I UNDERSTAND THAT EFT (ELECTRONIC FUNDS TRANSFER) (IE PAYROLL DIRECT DEPOSIT) IS A REQUIREMENT FOR MY BEING HIRED. I UNDERSTAND I MUST PROVIDE THE NECESSARY BANKING INFORMATION ON THE FORM I COMPLETE WITH ALL OF MY OTHER EMPLOYMENT PAPERWORK. I UNDERSTAND THAT IF THE EFT (ELECTRONIC FUNDS TRANSFER) PAPERWORK IS NOT RETURNED ALONG WITH MY OTHER PAPERWORK AT MY TIME OF HIRE, I WILL BE TERMINATED FOR FAILURE TO COMPLY WITH THIS CONDITION OF EMPLOYMENT.
First Name
Last Name
Date:
*
MM
DD
YYYY
