Employment Form

Employment Application
We appreciate your inquiry for employment. So that we can thoroughly consider your request, we ask for completion of this Employment Application. The application will remain valid for 30 days from the signing date. If you wish to still be considered after this date, a new application must be submitted.

Our company fully subscribes to the principles of Equal Employment Opportunity. Our policy is to provide employment, compensation, and other benefits related to employment based on qualifications, without regard to race, color, religion, national origin, age, sex, veteran status, disability, or any other basis prohibited by federal, state or local law. In accordance with requirements of the Americans With Disabilities Act, it’s our policy to provide reasonable accommodation upon request during the application process to eligible applicants in order that they may be given a full and fair opportunity to be considered for employment. Applicants are only accepted for positions currently available and will only be considered for 30 days from today’s date or until the position applied for are filled, whichever first occurs first.
Position Applied For:
Date:

MonthDayYear
Date
Personal Data:
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Salary Expectations:
If you are under 18 years of age, please specify your age here . This information will only be used for child labour law purposes. Are there any days, shifts, or hours you wil not work?
If yes, please explain:
Are you available for out of town work?
Will you work overtime, if required?
Have you taken any illegal drugs in the last 30 days?
When will you be able to start work?
Have you ever been a defendant in a civil action for an international tort (international commission of wrongful act)
Note: Answering “yes” to the previous question does not automatically exclude you from further consideration for the position. If yes, include nature of the international tort and the disposition of the action:
How did you learn of our company?
If referral, who were you referred by?
Have you ever applied for employment here before?
If yes, provide dates:
Are you legally authorized to work in the United States?
Will you now or in the future require sponsorship for employment visa status (e.g., H-1B visa status)
Note: The Federal Immigration and Reform and Control Act of 1986 requires that a DHS Employment Eligibility Verification Form I-9 be completed for every new hire and that within 3 business days of beginning work every new hire must present to the employer documentation establishing his/her identity and authorization to work. This federal requirement must be satisfied as a condition of employment.

Driving Record

(Answer only if driving is a requirement of the job for which you are applying)
Do you have a valid driver's license?
License:

StateLicense No.
Have you had any tickets?
If yes, please explain:
Do you have any DUI or DWI convictions?
If yes, please state when you were convicted and explain:

Residences

Please provide your address of residence for the past seven years beginning with the most recent address)
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
From:
To:

Residence 2
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
From:
To:

Residence 3
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
From:
To:

Residence 4
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
From:
To:

Education

(May or may not be considered depending on job applied for) Describe: Educational degrees, skills, training or experience you believe are relevant to the job applied for:

High School
Name, City, and State of Educational Institution:
Graduated?
If No, Degree Credits Earned:
Type of Degree received/expected:
Grade Point/Overall GPA

College/University:
Name, City, and State of Educational Institution:
Graduated?
If No, Degree Credits Earned:
Type of Degree received/expected:
Major
Minor
Grade Point/Overall GPA

Technical/GED
Name, City, and State of Educational Institution:
Graduated?
If No, Degree Credits Earned:
Type of Degree received/expected:
Major
Grade Point/Overall GPA

Licenses/Certifications/Other
Please list any Licenses/Certifications/Education Experience:

Employment History

(Please complete for all full-time or part-time employment beginning with your most recent employer. You may include as part of your employment history any verified work performed on a volunteer basis)

Employment 1
Company Name:
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dates Employed

FromTo
Name of Supervisor

First NameLast Name
May we contact?
Rate of Pay

StartLast
State job titles and describe job duties:
Reason for Leaving:

Employment 2
Company Name:
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dates Employed

FromTo
Name of Supervisor

First NameLast Name
May we contact?
Rate of Pay

Start Last
State job titles and describe job duties:
Reason for Leaving:

Employment 3
Company Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dates Employed

FromTo
Name of Supervisor

First NameLast Name
May we contact?
Rate of Pay

StartLast
State job titles and describe job duties:
Reason for Leaving:

Employment 4
Company Name:
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dates Employed

FromTo
Name of Supervisor

First NameLast Name
May we contact?
Rate of Pay

StartLast
State job titles and describe job duties:
Reason for Leaving:

References

Please list 3 persons not related to you who know their qualifications

Reference 1
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Relationship

Reference 2
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Relationship

Reference 3
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Relationship

Please explain any gaps in your employment history:
Have you ever been discharged or forced to resign?
If Yes, please explain:
Did you receive any discipline in the last 12 months of active employment?
If Yes, please explain:
Were you given a performance evaluation within the last 12 months of active employment?
If Yes, what was the range of scores used and what was your score?
Have you signed any non-compete or non-solicit agreements with any other company that may prevent you from working for the company?
If Yes, please explain: (you may be required to supply a copy of the agreement)
Military Service

Complete only if you served in the military

Service History
Branch of Service
Number of Years/Months of Service:
Rank at Discharge
Date of Discharge

MonthDayYear
Date
Reason for leaving:
Describe any military skills, training, or experience you believe may be relevant to the job you're applying for:

Criminal Record

All Applicants: You must answer all four of the following questions below. When answering the questions, you may exclude any records expunged, annulled, sealed, discharged, dismissed, erased under first-offender law or otherwise eradicated by statue or court order. You may also exclude a first conviction for any of the following misdemeanors; drunkenness, simple assault, speeding, minor traffic violations, affray or disturbance of peace.
A criminal conviction will not necessarily be a bar to employment but will be considered in relation to specific job requirements.
Have you been convicted of a felony within the last seven years?
If yes, Date of Conviction:

MonthDayYear
Date
Have you been convicted within the last seven years of misappropriation of funds, embezzlement, or other similar dishonest conduct; or an offense involving the use of a weapon; for burglary, robbery, breaking and entering or theft; or physical assault or other violent crime?
Have you been convicted of or completed a period of incarceration within the past five years for any misdemeanor?
A criminal conviction will not necessarily be a bar to employment. To help us evaluate your application, please describe your criminal conviction (s) including penalty (ies) imposed, listing the nature of your offense(s), and your rehabilitation since the conviction(s).

Applicants for Commercial Motor Vehicle Driver Positions
In order to drive a commercial motor vehicle, you must have a Commercial Driver’s License (CDL). Do you currently have a valid Commercial Driver’s License?
Please provide the following information for each unexpired motor vehicle license or permit which has been issued to you (include both CDL and non CDL)
Issuing State:
Number:
Expiration Date:
Indicate all CDL Endorsements and Restrictions you currently hold:

Double/Triple TrailersTank VehiclesHazardous MaterialsPassenger
If Applicate, Air Brake Restriction:
Driving Experience

Complete applicable sections, and leave non-applicable sections blank

Straight Truck
Dates

FromTo
Approximate Miles

Tractor Semi-Trailer
Dates

FromTo
Approximate Miles

Tractor Trailer
Dates

FromTo
Approximate Miles

Twin Trailer
Dates

FromTo
Approximate Miles

Triple Trailers
Dates

FromTo
Approximate Miles

Tankers
Dates

FromTo
Approximate Miles

Other (Please Specify):
Have you completed any special courses or training you believe will help you as a driver?
Have you received any safe driving awards
If yes, please specify when and from whom:
Have you been involved in any accidents (preventable and non-preventable) as a driver during the previous three years from the date of this application?

If yes, please provide the following information:

	Date	Nature of Accident (EG Head on, rear-end, overturn, etc.)	Fatalities (Number of)	Injuries (Number of)
Last Accident
Previous
Previous
Previous
Previous

Violations: Please list all violations of motor vehicle laws or ordinances (excluding parking) for which you have been convicted, or have forfeited a bond or collateral during the three years preceding this application.

	Date	Offense	Penalty	Type of Vehicle
1
2
3
4
5

Driving Privileges:
Has a State ever denied you a driver's license, permit, or privilege to operate a motor vehicle?
(Note: If you answered “yes”, and if you are subsequently interviewed, you will be required to provide a statement setting forth in detail the facts and circumstances)
Has a State ever suspended or revoked your driver's license, permit, or privilege to operate a motor vehicle?
(Note: If you answered “yes”, and if you are subsequently interviewed, you will be required to provide a statement setting forth in detail the facts and circumstances)
Have you ever been disqualified from driving for any of the following:
Driving a commercial vehicle with a blood alcohol concentration of .04 or more?
Driving under the influence of alcohol, as defined by State Law?
Refusing to submit to an alcohol test at the direction of the State, local or law enforcement personnel?
Driving a motor vehicle with a gross vehicle weight rating of 10,001 lbs. o more while under the influence of an illegal drug (including the improper use of a prescription drug)?
Transporting, possessing or using illegal drugs (including the improper use of a prescription drug) while on duty?
Leaving the scene of an accident while operating a commercial motor vehicle?
Committing a felony involving the use of a motor vehicle with a gross vehicle weight rating of 10,001 lbs or more?

Applicant Acknowledgement
“I CERTIFY THAT THE ANSWERS GIVEN HEREIN ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT, IF EMPLOYED, FALSIFIED INFORMATION ON THIS APPLICATION WILL BE GROUNDS FOR DISMISSAL I FURTHER UNDERSTAND THAT, IF EMPLOYED, THAT ANY FALSIFIED INFORMATION GIVEN MAY CAUSE FOR MY DISMISSAL AT ANY TIME WITHOUT ANY PRIOR NOTICE.”

“I AUTHORIZE THE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES AND EMPLOYERS LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY HAVE, PERSONAL OR OTHERWISE AND RELEASE THE COMPANY FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM UTILIZATION OF SUCH INFORMATION.”

“I ALSO AGREE AND UNDERSTAND THAT NO REPRESENTATIVE OF THE COMPANY HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIED PERIOD OF TIME, OR TO MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING, UNLESS IT IS IN WRITING AND SIGNED BY AN AUTHORIZED COMPANY REPRESENTATIVE.”

“I UNDERSTAND THAT APPLICANTS FOR CERTAIN POSITIONS MAY BE REQUIRED TO QUALIFY FOR EMPLOYMENT BASED ON ADDITIONAL EMPLOYMENT CRITERIA. I MAY BE REQUIED TO TAKE JOB RELATED TESTS; TAKE A DRIVER’S EXAMINATION; SUBMIT TO A BACKGROUND INVESTIGATION; TAKE A PREEMPLOYMENT DRUG TEST. IF I AM OFFERED EMPLOYMENT OR START WORKING BEFORE ANY REQUIRED TEST IS COMPLETED, MY EMPLOYMENT IS CONTINGEN ON A SATISFACTORY RESULT ON ALL REQUIED TESTS.”

“I ACKNOWLEDGE THAT THIS APPLICATION WILL REMAIN ACTIVE FOR 30 DAYS FROM TODAY’S DATE. IF I HAVE NOT HEARD FROM THE COMPANY AT THE CONCLUSION OF THIS 30 DAY PERIOD, IT IS MY RESPONSIBILTY TO COMPLETE A NEW APPLICATION IF I STILL WISH TO BE CONSIDERED FOR EMPLOYMENT.”
Signature:

Clear
Date:

MonthDayYear
Date
Should be Empty:

Employment Application

Personal Data:

Driving Record

Residences

Education

Employment History

References

Military Service

Criminal Record

Applicants for Commercial Motor Vehicle Driver Positions

Driving Experience

Driving Privileges:

Have you ever been disqualified from driving for any of the following:

Applicant Acknowledgement