Application for Employment Englund Equipment Company

The purpose of this application is to determine whether or not the applicant is qualified to operate motor carrier equipment according to the requirments of the Federal Motor Carrier Safety Regulations and the Company named above.
INSTRUCTIONS TO APPLICANT: Please answer all questions.
Today's Date*

MonthDayYear
Date
*The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age.
Choose One*

ContractorDriver
Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Emergency Phone Number*

Area CodePhone Number
*Age*
Date of Birth*

MonthDayYear
Date
Social Security Number*
Physical Exam Expiration Date*

MonthDayYear
Date
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
From: date* To: date* .
Previous Address 1*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
From: date* To: date* .
Previous Address 2*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
from: date To: date*
Previous Address 3*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
from: date To: date*
EDUCATION AND EMPLOYMENT HISTORY
Please indicate the highest grade completed (If none please write "NONE"):
Grade School (1-12):*
College(0-4):
Post Graduate (0-4):
Give a Complete Record of all employment for the past TEN years. Including all self-employment, all commercial driving experience, and unemployment. Begin with the most recent job.

FMCSA required.
Present or Last Employer:
Company Name
Position Held
Dates employed. From: date . To: date .
Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Supervisor Name
Reason For Leaving
Previous Employer:
Company Name
Position Held
Dates employed. From: date . To: blank .
Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Supervisor Name
Reason For Leaving
Past Employer:
Company Name
Position Held
Dates employed. From: date . To: blank .
Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Supervisor Name
Reason For Leaving
If you have completed 10 years of employment history click box below to jump to driving history:

Completed work history.
Click below if you need more employment history

More work history.

Please explain any gaps in employment:
Driving Experience

Class Of Equipment

	Dates (from:__To:__)	Type of Equipment (Van, Tank, Flat, etc.)	Approximate Total Mileage
Straight Truck
Tractor and Semi-trailer
Tractor-two trailers
Other

List all states or foreign countries operated in for the last five years
List all special courses/ training completed (Haz. Mat, PTD/DDC etc.)
List any Safe Driving Awards of special certificates you hold and from whom:
Accident Record for the past three years

	Date of Accident	Nature of Accident (Head on, rear end, etc.)	# Of people Injured	# of Fatalities
1
2
3
4
5
6

Traffic Convictions and Forfeitures for the last three years (All convictions, other than parking violations)

	State	Location	Charge	Penalty
1
2
3
4
5

List each drivers license held in the past 3 years

Licenses

	State	License #	Type	Endorsements	Expiration Date
1
2
3
4
5

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?

YesNo
B. Has any license, permit or privilege ever been suspended or revoked?

YesNo
C. Have you ever been convicted of a felony?

YesNo
D. Have you ever tested positive or refused a DOT drug or alcohol pre-employment test within the past two yearsfrom an employer who did not hire you?

YesNo
If you answered "yes" to A,B,C or D above please give details here:
PERSONAL REFERENCES

List three personal references, other than family members, who have knowledge of your safety habits.
Name: Address: Phone:Years Known:
Name: Address: Phone:blankYears Known:
Name: Address: Phone:blankYears Known:

TO BE READ AND SIGNED BY APPLICANT
It is agreed and understood that any misrepresentation given on this application for qualification shall be considered an act of dishonesty.

I give the motor carrier and its agents or representatives the right to investigate all references and to secure additional information about my employment background. I hereby release from all liability for damages the motor carrier and its agents or representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.

I agree to furnish such additional information and complete such examinations as may be required to complete my employment file.

It is agreed and understood that this application for qualification in no way obligates the motor carrier to employ me.

It is agreed and understood that if qualified to operate motor carrier equipment, I may be on a probationary period, during which I may be disqualified without recourse.
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.
Applicant's Signature

Clear
Date

MonthDayYear
Date
ENGLUND EQUIPMENT COMPANY

11498 W BUCKEYE RD CASHION,AZ 85329 PHONE 800-528-4075 FAX 623-936-6216
PRE-EMPLOYMENT DRUG/ALCOHOL TESTING CONSENT AND RELEASE FORM
I hereby consent to submit to a drug or alcohol test and to furnish a sample of my urine, breath, and/or blood for analysis, as shall be determined by

ENGLUND EQUIPMENT COMPANY in order to meet with their policy

regarding the selection of applicants for employment.

I further authorize and give full permission to have the Company and/or its authorized agents and physicians to send the specimen or specimens so collected to a laboratory for a screening test for the presence of any prohibited substances under the policy, and for the laboratory or other testing facility to release any and all documentation relating to such test to the Company. I further agree to and hereby authorize the release of the results of said tests to the Company.

I understand that it is the current use of illegal drugs that would prohibit me from being employed at this Company.

I further agree to hold harmless the Company and its agents and physicians from any liability arising in whole or part, out of the collection of specimens, testing, and use of the information from said testing in connection

with the Company's consideration of my application of employment.

I further agree that a reproduced copy of this pre-employment consent and release form shall have the same force and effect as the original.

If you are hired, you will be subject to the law requiring additional controlled substances and alcohol testing on you under numerous situations including, but not limited to the following:
Post-Accident -- Section 382.303

Random -- Section 382.305

Reasonable Suspension -- 382.307

Return to Duty -- 382.309

Follow-up -- 382.311

A Driver who test positive to a controlled substance(s) and/or alcohol test, will be immediately removed from a safety-sensitive position as required by Part 382 of the FMCSR, Federal law prohibits a Driver from returning to a safety-sensitive position for a motor carrier until and unless the Driver completes the Substance Abuse Professionals (SAP) evaluation, referral and education/treatment process as described in FMCSR Part 40, Subpart O.

I have carefully read the foregoing and fully understand its contents and testing requirements. I acknowledge that my signing of this consent and release form is a voluntary act on my part and that I have not been coerced into signing this document by anyone.
Applicant's Name
Social Security Number
Date*

MonthDayYear
Date
Applicant Signature*

Clear
ENGLUND EQUIPMENT COMPANY

11498 W BUCKEYE RD CASHION,AZ 85329 PHONE 800-528-4075 FAX 623-936-6216

REQUEST FOR CHECK OF DRIVING RECORD
I hereby authorize you to release the following information to ENGLUND EQUIPMENT COMPANY for purposes of investigation as required by Sections 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability which may result from furnishing such information.
Applicant's Signature*

Clear
Date*

MonthDayYear
Date
In accordance with the provisions of Sections 604 and 607 of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title 11, Subtitle D, Chapter 1, of Public Law 104-208), 1 hereby certify the following:

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 may be obtained for employment purposes; 3. The information requested below will be used for a ''permissible purpose'' (i.e., information for employment purposes) and will be used for no other purpose; 4. 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 receive a copy of the requested report and the summary of consumer rights as provided with the report by the consumer reporting agency.

I also hereby certify that this report request and the above applicant'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 103-322, Title XXX, Section 300002(a

The following Driver has made application with our company. In accordance with Section 391.23, Federal Department of Transportation Regulations, please furnish the undersigned with the applicant's driving record for the past 10 years.
NAME OF APPLICANT/DRIVER
COMPLETE ADDRESS:
FORMER ADDRESS:
DATE OF BIRTH:

MonthDayYear
Date
SSN*
LICENSE NO.*
Requested By:

COMPANY NAME / ADDRESS: ENGLUND EQUIPMENT COMPANY 11498 W. Buckeye Rd Cashion Az 85329
ENGLUND EQUIPMENT COMPANY

11498 W BUCKEYE RD CASHION,AZ 85329 PHONE 800-528-4075 FAX 623-936-6216
SAFETY PERFORMANCE HISTORY RECORDS REQUEST

Part 1:
Name*

First NameMiddle NameLast Name
TO BE COMPLETED BY PROSPECTIVE EMPLOYEE
Social Security Number*
Date of Birth*

MonthDayYear
Date
To release and forward the information requested by section 3 of this document concerning my Alcohol and Controlled Substances Testing records within the previous 3 years from: (employment application date)
Employment Application Date*

MonthDayYear
Date
To: Prospective Employer: ENGLUND EQUIPMENT COMPANY

Attention: Safety Department

Telephone: 1-800-528-4075

Street: 11498 W. Buckeye Rd Cashion Az 85329

In compliance with §40.25(g) and 391.23(h), the release of this information must be made in a written form that ensures confidentiality, such as fax, email, or letter.
Applicant's Signature*

Clear
Date

MonthDayYear
Date
This information is being requested in compliance with §40.25(g) and 391.23
Should be Empty:

Present or Last Employer:

Previous Employer:

Past Employer:

Past Employer:

Past Employer:

Past Employer:

Past Employer:

Past Employer:

Past Employer:

Past Employer:

Past Employer:

Past Employer:

Past Employer:

Past Employer:

Past Employer:

Driving Experience

PERSONAL REFERENCES

TO BE READ AND SIGNED BY APPLICANT

ENGLUND EQUIPMENT COMPANY

PRE-EMPLOYMENT DRUG/ALCOHOL TESTING CONSENT AND RELEASE FORM

ENGLUND EQUIPMENT COMPANY

REQUEST FOR CHECK OF DRIVING RECORD

ENGLUND EQUIPMENT COMPANY

SAFETY PERFORMANCE HISTORY RECORDS REQUEST

TO BE COMPLETED BY PROSPECTIVE EMPLOYEE