DRIVER'S APPLICATION FOR EMPLOYMENT

Transcription

1 DRVER'S APPLCATON FOR EMPLOYMENT Applicant Name Date of Application (print) Company Address City State n 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 SGNED BY APPLCANT 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.) 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. n the event of employment, understand that false or misleading information given in my application or interview(s) may result in discharge. understand, also, that am required to abide by all rules and regulations of the Company. understand that information 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 (d) and (e). understand that 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 cannot agree on the accuracy of the information. Signature Date FOR COMPANY USE PROCESS RECORD APPLCANT HRED DATE EMPLOYED REJECTED PONT EMPLOYED DEPARTMENT CLASSFCATON (F REJECTED, SUMMARY REPORT OF REASONS SHOULD BE PLACED N FLE) SGNATURE OF NTERVEWNG OFFCER TERMNATON OF EMPLOYMENT DATETERMNATED DEPARTMENT RELEASED DSMSSED VOLUNTARLY QUT OTHER TERMNATON REPORT PLACED N FLE SUPERVSOR This form is made available with the understanding that J. J. Keller & ASSOCiates, nc. is not engaged in rendering legal, accounting, or other professional services. J. J. Keller & ASSOCiates, nc. assumes no responsibility for the use of this form. or any decision made by an employer which may violate local. state, or federal J. J. KELLER & ASSOCATES, NC., Neenah, W USA (800) in the United States 15F (Rev. 6/08) 691

2 APPLCANT TO COMPLETE (answer all questions - please print) Posmon(s) Applied for Nrume_~ ~~ ~~~ Last First Middle Social Security No. Ust your addresses of residency for the past 3 years. Current Address --=-:---:-- ~;:;;:_: Street City Previous Addresses Phone How Long? State Zip Code yr.lmo. How Long? Street City State & Zip Code yr.lmo. How Long? How Long? Street City State & Zip Code yr.lmo. Do you have the legal right to work in the United States? Date of Birth (Required for Commercial Drivers) Have you worked for this company before? Can you provide proof of age? Where? Dates: From To Rate of Pay Position Reason for leaving Are you now employed? f 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? f 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. s 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]? f yes, explain if you wish. EMPLOYMENT HSTORY 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 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 with the most recent. Add another sheet as necessary.) NAME EMPLOYER CONTACT PERSON PHONE NUMBER WERE YOU SUBJECT TO THE FMCSRst WHLE EMPLOYED? DYES D NO DATE TO MO. YR. MO. POSTON HELD SAJ..ARYWAGE REASON FOR leavng TESTNG REQUREMENTS OF 49 CFR PART 40? 0 YES 0 NO PAGE 2 15F (Rev. 6108) 691 YA.

3 EMPLOYMENT HSTORY (continued) EMPLOYER TO. NAME MO. YA. MO. YA. POSTON HELD. CONTACT PERSON PHONE NUMBER SALARYWAGE DATE REASON FOR LEAVNG WERE YOU SUBJECT TO THE FMCSRs t WHLE EMPLOYED? DYES D NO TESTNG REQUREMENTS OF 49 CFR PART 40? DYES D NO EMPLOYER NAME MO. YA. MO. YR. POSTON HELD CONTACT PERSON PHONE NUMBER SALARYWAGE DATE REASON FOR LEAVNG TO WERE YOU SUBJECT TO THE FMCSRstWHLE EMPLOYED? DYES D NO TESTNG REQUREMENTS OF 49 CFR PART 40? DYES D NO NAME! EMPLOYER CONTACT PERSON PHONE NUMBER DATE TO MO. YA. MO. POSTON HELD SALARYWAGE REASON FOR LEAVNG YA. WERE YOU SUBJECT TO THE FMCSRstWHLE EMPLOYED? DYES D NO TESTNG REQUREMENTS OF 49 CFR PART 40? DYES D NO EMPLOYER DATE i TO NAME MO. YR. MO. YR. POSTON HELD SALARYWAGE REASON FOR LEAVNG CONTACT PERSON PHONE NUMBER i WERE YOU SUBJECT TO THE FMCSRstWHLE EMPLOYED? DYES D NO TESTNG REQUREMENTS OF 49 CFR PART 40? DYES D NO EMPLOYER DATE NAME TO MO. YR. MO. YR. POSTON HELD CONTACT PERSON PHONE NUMBER WEREYOU SUBJECT TO THE FMCSRstWHLE EMPLOYED? DYES D NO SALARYWAGE REASON FOR LEAVNG TESTNG REQUREMENTS OF 49 CFR PART 40? DYES D NO "ncludes vehicles having a GVWR of 26,001 bs. 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. tthe 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 10,001 pounds 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 materials in a quantity requiring placarding. PAGE 3 15F (Rev.608) 691

4 ACCDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET F MORE SPACE S NEEDED) F NONE, WRTE NONE NATURE OF ACCDENT DATES FATALTES NJURES (HEAD ON, REAR-END. UPSET. ETC.) HAZARDOUS MATERAL SPLL LAST ACCDENT NEXT PREVOUS NEXT PREVOUS TRAFFC CONVCTONS AND FORFETURES FOR THE PAST 3 YEARS (OTHER THAN PARKNG VOLATONS) F NONE. WRTE NONE LOCATON ~ CHA~E PENALTY Driver licenses or permits held in the past 3 years (ATTACH SHEET F MORE SPACE S NEEDED) EXPERENCE AND QUALFCATONS - DRVER STATE LCENSE NO. CLASS ENDORSEMENT(S) EXPRATON 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 F THE ANSWER TO ETHER A OR B S YES, GVE DETALS DRVNG EXPERENCE CHECK YES OR NO CLASS OF EQUPMENT STRAGHT TRUCK TRACTOR AND SEM TRALER TRACTOR TWO TRALERS TRACTOR - THREE TRALERS MOTORCOACH SCHOOLBUS MOTORCOACH-SCHOOLBUS OTHER DYES DNO DYES DNO DYES DNO DYES DNO More than 8 DYES 0 NO passengers DYES [J NO ~a':mu:s15 C~RCLE TYPE OF EQUPMENT K. FLAT. DUMP, REFER) (VAN. TANK. FLAT. DUMp, REFER) (VAN. TANK. FLAT, DUMP, REFER) (VAN, TANK, FLAT. DUMP, REFER) - - DATES (MY) TO (MY) APPROX. NO. OF MLES (TOTAl) LST STATES OPERATED N FOR LAST FVE YEARS: SHOW SPECAL COURSES OR TRANNG THAT WLL HELP YOU AS A DRVER: WHCH SAFE DRVNG AWARDS DO YOU HOLD AND WHOM? EXPERENCE AND QUALFCATONS - OTHER SHOW ANY TRUCKNG, TRANSPORTATON OR OTHER EXPERENCE THAT MAY HELP N YOUR WORK FOR THS COMPANY LST COURSES AND TRANNG OTHER THAN SHOWN ELSEWHERE N THS APPLCATON LST SPECAL EQUPMENT OR TECHNCAL MATERALS YOU CAN WORK WTH (OTHER THAN THOSE ALREADY SHOWN) EDUCATON CRCLE HGHEST GRADE COMPLETED: B HGH SCHOOL: COLLEGE: LASTSCHOOLATTENDED~(N~AM~E~) ~!C~T~.~~~A! ~ TO BE READ AND SGNED BY APPLCANT 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. Signature: Dnfl: PAGE 4 15f (Rev. 6108) 691

5 Company Name FAR CREDT REPORTNG ACT DSCLOSURE STATEMENT n accordance with the provisions ofsection 604(b )(2)(A) ofthe Fair Credit Reporting Act, Public Law , as amended by the Consumer Credit Reporting Act of 1996 (Title, Subtitle D, Chapter, ofpublic Law ), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. These reports are required by Sections , , and ofthe Federal Motor Carrier Safety Regulations. Applicant's signature Date Print name Social Security number Copyrigh1998 J. J. KELLER & ASSOCATES, NC., Neenah, W' USA' (800) ' Printed in the Untted States 16-F-A (Rev, 7/98)

6 REQUEST FOR CHECK OF DRVNG RECORD NOTE TO MOTOR CARRER: SEE BACK SDE FOR STATES THAT ACCEPT THS FORM. hereby authorize you to release the following information to (Prospective Employer) for purposes of investigation as required by Sections and of the Federal Motor. qarriersafety Regulations. You are released from any and all liability which may result from furnishing such information.. (Applicant's Sigmiture) (Date)..."...,...,,,...,',...,.,...,... '...:: ~.:.~...'... ~...;... ~... ~~...:.... '... '..._:'...,'...,...,... ~...,...;.'... '... '... ~.:,...:... n accordance with the provisions of Sections 604 and 607 Of the Fair Credit Reporting Act, Public Law , a!'3 amended by the Consumer Credit Reporting Act of 1996 (Title, Subtitle 0, Chapter 1, of Public Law ), here,bycertifythefol6wing:. 1. The consumer (applicant) has authorized in writing the procurement of this report;..., ".....'.. 2. The consumer (applicant) has been informed in a separate written disclosure that a consumer report maybe,obtained for employment purposes;' The information requested below will be used for a "permissible purpose" (Le., information for employment purposes) and will be used for no other purpose; The information being obtained will not be used.in violation of any federal or state equal opportunity law or regulation; and 5. Before taking an adverse action based in whole or in part on the report the consumer (applicant) will rece.ive a copy of the requested report and the summary of consumer: rig~ts as provided with the report by the consumer reporting agency. also hereby certify that this report requ~st and tp~ above '~pplicant's release notice meet the definition of "permissible uses" of state motor vehicle records under the provisions of the Driver's Privacy Protection Act of 1994 (PubliC Law , Title XXX, Section (a». TO: (Signature of Requester) (Date),' DEAR SR/MADAM: D The following named person has made application with our company for the position of -'--..naccordance with Section , Federal Department of Transportation Regulations, please furnish the undersigned with the applicant's driving record for the past three years. D The following named person is employed with our company in the position of ~ ' ~ ~.---"---'-i-.. n accordance with Section , Federal Department of Transportation Regulations, please furnish the undersigned with tl:1e employee's driving record for the past year. NAME OF APPLCANT/DRVER -'---c ~: ,--- ~~~~~~--~- --~~-----~~------~~~~----- (Number & Street) (City) (State) (Zip COd.e). FORMER~~~~=_~--~--~~----~~ ~~ =~~~~~ (Number & Street) (City) (State) (Zip Code) DATE OF BRTH SSN --,- LCENSE NO. REQUESTED BY (Typed Name) (Address) (Title) (Signature) Copyright 2008 J. J. KELLER & ASSOCATES, NC., Neenah, W- USA - (800) in the United States 16-F 729 (Rev. 1/08)

7 PREVOUS EMPLOYEE SAFETY PERFORMANCE HSTORY Pursuant to a request for Previous Employee Safety Performance History. Dated this response is being provided to the Prospective Employer noted below in compliance with the Department of Transportation regulations (g)(1) and (b). Corrected Copy, Replaces Response Dated: TO BE COMPLETED BY THE PREVOUS EMPLOYER DRVER DENTFCATON Name of Previous Employee: [J DOT Regulated Driver Social Security No.: Date of Birth: D Non-DOT Regulated Driver Employed from to as PREVOUS EMPLOYER NFORMATON CompanyName: PhoneNumber: Contact Name: Street City. State, Zip: Company Name: Attention: PROSPECTVE EMPLOYER NFORMATON THS FORM WAS (check appropriate box) Mailed,Date: Street: Faxed, Date: City, State. Zip: D ed, Date: Phone Number: Relayed by Phone, Date: Name of Person Contacted: SAFETY PERFORMANCE HSTORY D There is no safety performance history to report. Driver operated a: D Straight Truck D Tractor-Semitrailer D Bus D Cargo Tank D DoublesfTriples D Other (Specifyl Driver did not operate a motor vehicle. Reason for leaving employ: D Discharged D Resignation Lay Off D Military Duty ACCDENTS: Date Location No. of njuries No. of Fatalities Hazmat Material Spill No accident register data for this driver. Enclosed is other accident information pursuant to the employer's internal policies for retaining minor accident information ( (d)(2)(ii». DRUG/ALCOHOL TESTNG: D Prospective employer did not provide signed release from driver ( (b)). Therefore, drug/alcohol information cannot be provided. Under DOT drug and alcohol testing requirements for the past 3 years: Yes No 1. This person was employed in a safety-sensitive function that required alcohol and controlled substances testing specified by 49 CFR Part 40 (if NO, skip this section). D 0 2. This person had an alcohol test with a result of 0.04 or higher alcohol concentration. D D 3. This person tested positive or adulterated or substituted a test specimen for controlled substances. D 0 4. This person refused to submit to a post-accident, random, reasonable suspicion. or follow-up alcohol or controlled substance test. D D 5. This person committed other violations of Subpart B of Part 382, or Part D 6. This person violated a DOT drug and alcohol regulation and completed a SAP-prescribed rehabilitation program in our employ, including return-to-duty and follow-up tests. f yes, documentation is enclosed. D 0 7. This person, after successfully completing a SAP's rehabilitation referral, remained in our employ but subsequently had an alcohol test result of 0.04 or greater, a verified positive drug test, or refused to be tested. D D n providing this information, any drug or alcohol testing information obtained from previous employers under or other applicable DOT regulations is included. Any other remarks: Signature: Title: Date: FOR PREVOUS EMPLOYER'S RECORD - KEEP A RECORD OF EACH REOUEST AND THE RESPONSE FOR ONE YEAR, NCLUDNG THE DATE, THE PARTY TO WHOM T WAS RELEASED, AND A SUMMARY DENTFYNG WHAT WAS J, J, KELLER & ASSOCATES, NC" Neenah, W- (800) Wlvw,llkeller,com - Printed in the United States 854-F 9619

8 Motor Vehicle Driver's CERTFCATON OF COMPLANCE WTH DRVER LCENSE REQUREMENTS MOTOR CARRER NSTRUCTONS: The requirements in Part 383 apply to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle weighing 26,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding. The requirements in Part 391 apply to every driver who operates in interstate commerce and operates a vehicle weighing 10,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding. DRVER REQUREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain certain driver licensing requirements that you as a driver must comply with, including the following: 1) POSSESS ONLY ONE LCENSE: You, as a commercial vehicle driver, may not possess more than one motor vehicle operator's license. 2) NOTFCATON OF LCENSE SUSPENSON, REVOCATON OR CANCELLATON: Sections (b)(2) and of the Federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSNESS DAY of any revocation or suspension of your driver's license. n addition, Section requires that any time you are convicted of violating a state or local traffic law (other than parking), you must report it within 30 days to: 1) your employing motor carrier, and 2) the state that issued your license (if the violation occurs in a state other than the one which issued your license). The notification to both the employer and state must be in writing. 3) COL DOMCLE REQUREMENT: Section (a)(2) requires that your commercial driver's license be issued by your legal state of domicile, where you have your true, fixed, and permanent home and principal residence and to which you have the intention of returning whenever you are absent. f you establish a new domicile in another state, you must apply to transfer your CDL within 30 days. The following license is the only one possess: Driver's License No. State Exp. Date DRVER CERTFCATON: certify that have read and understood the above requirements. Driver's Name (Printed): Driver's Signature: Date: Nmes: (This form is nol required for DOT compliance.) goof 1617 Copyrighl200s J. J. KELLER & ASSOCATES, NC., Neenah, W- USA - (600) ' in he United States (Rev. 3/08)