"*" indicates required fields Δ 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, or disability. Date of application* MM slash DD slash YYYY Positions(s) Applied for*Are you available to work: (Please check all the apply)* Full Time Part Time Shift Work Temporary Work Last Name*First Name*MI*SS#*Email* Current Address* Street Address City State Zip How Long*Previous Address* Street Address City State Zip How Long*Previous Address Street Address City State Zip How LongDate of Birth* MM slash DD slash YYYY (Required for Commercial Drivers)Can you provide proof of age?* Yes No Do you have the legal right to work in the United States?* Yes No Have you ever filed an application with us before?* Yes No If yes, give date: MM slash DD slash YYYY Have you ever been employed with us before?* Yes No If yes, give dates (FROM): MM slash DD slash YYYY TO: MM slash DD slash YYYY PositionReason for leavingAre you now employed?* Yes No If yes, may we contact your present employer? Yes No Who referred you?*Rate of Pay Expected*Have you been convicted of a felony within the last 7 years?* Yes No If yes, please explain: Employment History All applicants with a commercial drivers license must provide 10 years of employment information. If employed for less than 10 years all employment history must be listed. Employer #1Name*From* MM slash DD slash YYYY To* MM slash DD slash YYYY Address* Street Address City State Zip Position*Wage/Salary*Contact Person*Phone*Reason for leaving* Employer #2NameFrom MM slash DD slash YYYY To MM slash DD slash YYYY Address Street Address City State Zip PositionWage/SalaryContact PersonPhoneReason for leaving Employer #3NameFrom MM slash DD slash YYYY To MM slash DD slash YYYY Address Street Address City State Zip PositionWage/SalaryContact PersonPhoneReason for leaving Employer #4NameFrom MM slash DD slash YYYY To MM slash DD slash YYYY Address Street Address City State Zip PositionWage/SalaryContact PersonPhoneReason for leaving Employer #5NameFrom MM slash DD slash YYYY To MM slash DD slash YYYY Address Street Address City State Zip PositionWage/SalaryContact PersonPhoneReason for leaving Employer #6NameFrom MM slash DD slash YYYY To MM slash DD slash YYYY Address Street Address City State Zip PositionWage/SalaryContact PersonPhoneReason for leaving Certifications List any certifications below ASE*ASEExpiration Add RemoveEVT*EVTExpiration Add RemoveMANUFACTURER* Allison Transmissions CAT Cummins Detroit Diesel Mercedes Engines Hale Pumps Waterous Pumps Spartan Chassis Meritor Heavy Truck Alignment Other Add manufacturer information hereOther (Expiration) MM slash DD slash YYYY Other (Engine, transmission, series, etc. )Allison Transmissions (Expiration) MM slash DD slash YYYY Allison Transmissions (Engine, transmission, series, etc. )CAT (Expiration) MM slash DD slash YYYY CAT (Engine, transmission, series, etc. )Cummins (Expiration) MM slash DD slash YYYY Cummins (Engine, transmission, series, etc. )Detroit Diesel (Expiration) MM slash DD slash YYYY Detroit Diesel (Engine, transmission, series, etc. )Mercedes Engines (Expiration) MM slash DD slash YYYY Mercedes Engines (Engine, transmission, series, etc. )Hale Pumps (Expiration) MM slash DD slash YYYY Hale Pumps (Engine, transmission, series, etc. )Waterous Pumps (Expiration) MM slash DD slash YYYY Waterous Pumps (Engine, transmission, series, etc. )Spartan Chassis (Expiration) MM slash DD slash YYYY Spartan Chassis (Engine, transmission, series, etc. )Meritor (Expiration) MM slash DD slash YYYY Meritor (Engine, transmission, series, etc. )Heavy Truck Alignment (Expiration) MM slash DD slash YYYY Heavy Truck Alignment (Engine, transmission, series, etc. )EXPERIENCE* Allison Transmissions CAT Cummins Detroit Diesel Mercedes Engines Hale Pumps Waterous Pumps Spartan Chassis Meritor Heavy Truck Align Allison Transmission ( Engine, transmission, series, etc. )CAT ( Engine, transmission, series, etc. )Cummins ( Engine, transmission, series, etc. )Detroit Diesel ( Engine, transmission, series, etc. )Mercedes Engines ( Engine, transmission, series, etc. )Hale Pumps ( Engine, transmission, series, etc. )Waterous Pumps ( Engine, transmission, series, etc. )Spartan Chassis ( Engine, transmission, series, etc. )Meritor ( Engine, transmission, series, etc. )Heavy Truck Align ( Engine, transmission, series, etc. ) Accident Record & Driving Record Accident Record for Past 3 Years or More. If None, Write None Last Accident MM slash DD slash YYYY Nature of Accident (Head-On, Rear-End, Upset, Etc.)*Fatalities*InjuriesNext PreviousDateNature of Accident (Head-On, Rear-End, Upset, Etc.)FatalitiesInjuries Add RemoveTraffic convictions and forfeitures for the past 3 years (other than parking violations) if none, write none*LocationDateChargePenalty Add Remove Education Highest Grade Completed* 1 2 3 4 5 6 7 8 High School* 1 2 3 4 College* 1 2 3 4 Last School Attended*City*State* Driver Qualifications Driver*StateLicense #TypeExpiration Date Add RemoveHave you ever been denied a license, permit or privilege to operate a motor vehicle?* Yes No Please give some detailsHas any license, permit or privilege ever been suspended or revoked?* Yes No Please give some details Driving Experience, If None, Write None Class of Equipment* Straight Truck Tractor & Semi-Trailer Tractor-Two Trailers Motor Coach School Bus Other Type of Equipment (Van, Tank, Flat, Etc.)Straight TruckDates ( From - To )Straight TruckApproximate # of MilesStraight TruckType of Equipment (Van, Tank, Flat, Etc.)Tractor & Semi-TrailerDates ( From - To )Tractor & Semi-TrailerApproximate # of MilesTractor & Semi-TrailerType of Equipment (Van, Tank, Flat, Etc.)Tractor-Two Trailers Dates ( From - To )Tractor-Two Trailers Approximate # of MilesTractor-Two TrailersType of Equipment (Van, Tank, Flat, Etc.)Motor Coach Dates ( From - To )Motor CoachApproximate # of MilesMotor CoachType of Equipment (Van, Tank, Flat, Etc.)School BusDates ( From - To )School BusApproximate # of MilesSchool BusType of Equipment (Van, Tank, Flat, Etc.)OtherDates ( From - To )OtherApproximate # of MilesOtherList States Operated In For Last Five Years*Show Special Courses or Training That Will Help You As A Drive*Which Safe Driving Awards Do You Hold and From Whom?* Experience & Qualifications – Other Show any trucking, transportation or other experience (not listed elsewhere on the application) that may help in you work for this company*List courses and training (other than those shown elsewhere in this application)*List special equipment or technical materials you can work with (other than those already shown)*Note to Applicants: Do not answer this question unless you have been informed about the requirements of the job for which you are applying.Are you capable of performing in a reasonable manner, with or without reasonable accommodation, the activities involved in the job or occupation for which you have applied?* Yes No TO BE READ AND SIGNED BY APPLICANTThis 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. I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history, criminal record, 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 leasing 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. Date* MM slash DD slash YYYY Signature*
