Driver Employment Application

Employment Application Form:

Tri-County Electric Membership Corporation
Personal Information:
Full Name*

First NameMiddle NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date Available for Work*

MonthDayYear
Date
Position Applying For:*
Previous Residency

Attach additional sheet if more space is needed
You are required to provide each of the addresses in which you have had resided over the past 3 years. If you have resided at your current address continuously for the past 2 years, leave this section blank.
Previous Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number of Years at address:
number of years
Previous Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number of Years at address:
number of years
Previous Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number of Years at address:
number of years
License Information
No person who operates a commercial motor vehicle shall at any time have more than one driver's license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below. Include all licenses held for the past 3 years; attach additional sheets if necessary.

CURRENT License Information*

Rows	State	Type/Class	Endorsements	Expiration Date	License Number
Current License

YesNo

Previous Held License(s)*

Rows	State	Type/Class	Endorsements	Expiration Date
Previous
Previous
My Current License is the only Professional License I have had. Enter YES if your current license is your only license.

Driving Experience

Driving Experience:*

Rows	Type of Equipment (Van, Tank, Flat, etc)	Date From	Date To	Approximate Number of Miles (Total)?
Straight Truck
Tractor & Semi-Trailer
Tractor & 2 Trailers
Tractor & Tanker
Other

Accident Record for the Past 3 Years:

Attach additional sheet if more space is needed.

Accident Record*

Rows	Nature of Accident (Head-on, Rear-end, upset, etc.)	#Fatalities	#Injuries	Chemical Spills? Yes/No
Dates Most Recent
Date 2nd Most Recent
Date 3rd Most Recent
I have no accidents in the past 3 years. Enter None

YesNo
Traffic Convictions and Forfeitures for the Past 3 Years (Other than Parking Violations)

Attach additional sheet if more space is needed.

Traffic Convictions & Forfeitures*

Rows	Violations	State of Violation	Penalty (Forfeited bond, collateral and/or Points
Date Convicted Month/Year
Date ConvictedMonth/Year
Date Convicted Month/Year
Date Convicted Month/Year
I have no Traffic Convictions/ Forfeitures in the past 3 years (enter NONE)

YesNo
YesNo
If Yes, explain:
YesNo
If Yes, explain:
Employment Disclosures
I understand that upon employment, proof of legal right to work in the United States and completion of I-9 form will be required.
YesNo
YesNo
If yes, explain:
How did you learn of the vacancy?*
YesNo
If no, what accommodation would make it possible for your to perform this job?
YesNo
If yes, indicate position, department and dates:
YesNo
If yes, who?
Tri-County Electric Membership Corporation is an equal opportunity employer and recruits, advertises, employs, promotes, transfers, disciplines and discharges without regard to race, color, religion, national origin, age, sex, marital status, ancestry, physical or mental disability or veteran status.

Tri-County Electric Membership Corporation is a smoke-free work environment.
Education & Training:
High School
Name of High School Attended
Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number of Years Attended
YesNo
College
Name of College/University Attended
Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number of Years Attended
YesNo
Details/Area of Study/Degree
Other
Name of Program Attended
Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number of Years Attended
YesNo
Details/Area of Study/Degree
Lineman Training Program Certification
Name of Vocational Technical/Other School Attended
Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number of Years Attended
GPA
Yes
Please list any other qualifications that you have and which you believe should be considered:
List any relevant certifications or qualifications or experiences
Employment History:

MUST BE COMPLETED EVEN IF ATTACHING A RESUME
The Federal Motor Carrier Safety Regulations (49 CFR 391.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last three (3) consecutive years.

In addition, if you have driven a commercial vehicle previously, you must provide employment history for an additional seven (7) years (for a total of ten (10) yeras). Any gaps in employment in excess of one (1) month must be explained.

Start with the last or current position, including any military experience, and work backwards (attach separate sheets if necessary). You are required to list the complete mailing address, including street number, city, state, zip; and complete all other information.
List your last three employers with the most recent first:
Current or Most Recent Employer*
Name of Current Employer or NONE if not Employed
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Position Held*
Start Date*

MonthDayYear
Date
End Date

MonthDayYear
Date
Reason for Leaving?*
Current Salary*
Explain any gaps in employment (include month/year and reason):*
Gaps in employment. If none, state none
YesNo
YesNo
Previous Employment:
2nd Most Recent Employer*
Name of Previous Employer
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Position*
Ending Salary*
Start Date*

MonthDayYear
End Date*

MonthDayYear
Reason for Leaving?*
Explain any gaps in employment (include month/year and reason):*
Gaps in employment. If none, state none
YesNo
YesNo
Third Most Recent Previous Employer*
Name of Previous Employer
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Position*
Ending Salary*
Start Date*

MonthDayYear
End Date*

MonthDayYear
Reason for Leaving?*
Explain any gaps in employment (include month/year and reason):*
Gaps in employment. If none, state none
YesNo
YesNo
Professional References:

Please list only references that we may contact at this time.
Reference 1*
Name of Reference
Title*
Company*
Phone*
Email*
Reference 2*
Name of Reference
Title*
Company*
Phone*
Email*
Reference 3*
Name of Reference
Title*
Company*
Phone*
Email*
Additional Information:
Cover Letter

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Resume

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Upload Any Additional Residency Information

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Upload any Additional Employment Information

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Upload additional Accident Records for the past 3 years

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Upload Additional Traffic Convictions & Forfeiture for the past 3 years (other than parking violations)

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Send Application:
By clicking the submit button below,

I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, health care providers, and other persons from all liabiity in repsonding to inquiries and releasing 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 also understand that I am required to abide by all rules and regulations of the Company.

I understand that the information I provide regarding my current and/or prior 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 391.23. I understand that I have the right to:
- Review information provided by current/previous employers;
- Have errors in the information corrected by previous emplyers, and for those previous employers to resend the corrected information to the prospective employer; and
- Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.
This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations.
Applicant's Signature*

Clear
Date*

MonthDayYear
Date
Applicant Name Printed
Should be Empty:

Employment Application Form:

Personal Information:

Previous Residency

License Information

Driving Experience

Accident Record for the Past 3 Years:

Traffic Convictions and Forfeitures for the Past 3 Years (Other than Parking Violations)

Employment Disclosures

Education & Training:

Employment History:

Previous Employment:

Professional References:

Additional Information:

Send Application: