Employment Application Page

Applicant’s Name*

Phone*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Position Applied For*

Branch location being applied to*

Where did you hear about this position?*

Online Job Board*

Other Name*

Are you seeking*

Full-Time
Part-Time
Temporary Employment?

When could you start work?*

Are you 18 years of age or older? (If hired, you may be required to submit proof of age)*

Yes
No

If hired, can you furnish proof you are eligible to work in the U.S.?*

Yes
No

Have you ever applied with the Company before?*

Yes
No

If yes, when?*

Have you ever been employed by the Company before?*

Yes
No

If yes, when?*

If yes, which branch / location?*

How were you referred to the Company for employment?*

If employed, do you expect to be engaged in any additional business or employment outside of the Company?*

Yes
No

If yes, give details?*

For positions requiring a driver license, do you have a valid driver license?*

Yes
No
N/A

Have you ever had your driver license suspended or revoked?*

Yes
No
N/A

If yes, give details?*

FOR POSITIONS REQUIRING A DRIVER LICENCE, ACCIDENT RECORD FOR THE PAST 3 YEARS (Attach sheet if more space is needed) If none, write None.

Date	Nature of Accident (Head-on, Rear-End, Lane Change, etc.)	Fatalities	Injuries

FOR POSITIONS REQUIRING A DRIVER LICENSE, TRAFFIC CONVICTIONS / FOREFEITURES FOR PAST 5 YEARS (Other than parking violations) If none, write None.

Location	Date	Charge	Penalty

List professional, trade, business, or civic activities and offices held (exclude labor organizations and memberships which reveal race, color, religion, national origin, sex age, disability, or other protected status.)

List your addresses of residency for the past 3 years:

List your addresses of residency for the past 3 years:*

Street Address	City	State	Zip Code	Years / Months

(List name and address) Number of Years Completed Diploma/Degree Subjects Studied

High School or GED*

College or University*

Vocational or Technical*

What skills or additional training do you have that relate to the job for which you are applying?*

What machines or equipment can you operate that relate to the job for which you are applying?:*

List names of employers in consecutive order with present or last employer listed first. Account for all periods of time, including military service and any periods of unemployment. If self-employed, give firm name and supply business references. Note: Job offers may be contingent upon acceptable references from employers

NAME OF EMPLOYER*

JOB TITLE*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

DATE OF EMPLOYMENT (MO/YR):

From*

To*

Federal Motor Carrier Position*

Yes
No

Position Subject to Drug Testing*

Yes
No

SUPERVISOR(S)*

TELEPHONE*

REASON FOR LEAVING*

NAME OF EMPLOYER

JOB TITLE

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

DATE OF EMPLOYMENT (MO/YR):

From

To

Federal Motor Carrier Position

Yes
No

Position Subject to Drug Testing

Yes
No

SUPERVISOR(S)

TELEPHONE

REASON FOR LEAVING

NAME OF EMPLOYER

JOB TITLE

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

DATE OF EMPLOYMENT (MO/YR):

From

To

Federal Motor Carrier Position

Yes
No

Position Subject to Drug Testing

Yes
No

SUPERVISOR(S)

TELEPHONE

REASON FOR LEAVING

Have you worked or attended school under any other names?*

Yes
No

If yes, give details?*

Are you presently employed?*

Yes
No

If yes, may we contact your current employer*

Yes
No

Have you ever been fired from a job or asked to resign?*

Yes
No

If yes, please explain:

References: Please give two references (No relatives or former employers)*

Name	Phone	Email Address

PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING
I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date, and I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employers and organizations to provide relevant information and opinions that may be useful in making a hiring decision including but not limited to the applicant’s driving record for the past three (3) years in accordance with Section 391.23 of the Federal Motor Carrier Safety Regulations and information on the driver’s alcohol tests with a concentration of 0.04 or greater, positive controlled substances test results, and refusals to be tested within the preceding two years and other information as allowed by Sections 382.413(a)(b)(c)(e)(f) of the FMCSR. I release such persons and organizations from any legal liability in making such statements. I understand I may be required to successfully pass a drug screening examination. I hereby consent to a pre- and/or post-employment drug screen as a condition of employment, if required.

I UNDERSTAND THAT THIS APPLICATION, VERBAL STATEMENTS BY MANAGEMENT, OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE AN EXPRESSED OR IMPLIED CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. ONLY THE PRESIDENT OF THE ORGANIZATION HAS THE AUTHORITY TO ENTER INTO AN AGREEMENT OF EMPLOYMENT FOR ANY

SPECIFIED PERIOD AND SUCH AGREEMENT MUST BE IN WRITING, SIGNED BY THE CHIEF EXECUTIVE OFFICER AND THE EMPLOYEE. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT REASON AND WITH OR WITHOUT NOTICE.

I have read, understand, and by my signature consent to these statements.

Signature*