Employment Application

APPLICATION FOR EMPLOYMENT

We Are an Equal Opportunity Employer
Cheney Brothers, Inc. is an equal opportunity employer and adheres to all local, state, and federal laws prohibiting discrimination in employment whether on the basis of race, sex, religion, disability, national origin, age or any other protected class. Our company is committed to a drug-free and smoke-free workplace. By signing this application, you agree to submit to a pre-employment drug test prior to being considered for employment as outlined in our Drug Free Work Place Policies. All applicants must successfully pass the pre-employment drug test prior to being considered for employment. On-going random, post-accident, and reasonable suspicion drug testing is a requirement of all employees of the company in accordance with our Drug Free Work Place Policy.

Your application will be given every consideration, but its receipt does not imply that you will be contacted or employed.

Answer each section completely. Do not leave any blanks. If a section or question does not apply to you, answer with N/A. Incomplete applications will not be considered. Attachment of resumes or other documents does not substitute for a fully completed application. This application for employment will be considered active for a period of time not to exceed 60 days from the date of application. Any applicant wishing to be considered for employment beyond this time may have to reapply. Thank you for your consideration of employment with Cheney Brothers, Inc.
NOTICE TO ALL APPLICANTS - We are required by Court Order to make inquiry and obtain a signature of all applicants (except drivers) whether currently or previously employed with GFS Holdings DBA Henry Lee/Smart and Final*
If Yes, Please Provide Dates of Employment and Position Below
If you answered YES to the question above, please provide your Dates of Employment and Position
Date toDate Positionblanks
Application Date*

MonthDay Year
What Position Are You Applying For?*
If the position for which you are applying is not listed, please select Other and type in the name of the position.
Please Identify the Other Position for Which You Are Applying.*
At Which Location Are You Applying for a Position?*
If the location/yard for which you are applying for a positions is not listed, please select Other and type in the city and state of the location/yard
Please Identify the Other Location or Yard
Name*

First Name Middle Name Last Name Suffix
Current Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Have you resided at the above address for LESS than three (3) years? *
If you answered YES to this question, please identify your prior address(es) in the fields below
Prior Address 1 (Only required if you have not lived in your Current Address for at least 3 years)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Prior Address 2 (Only required if you have not lived in your Current Address for at least 3 years)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Are you related to any employee that currently works for Cheney Brothers?*
If you answered YES to the question above, what is the employee's name?

Are you over the age of 18?*
Can you provide proof of your eligibility to become lawfully employed in the United States either by way of Visa/Immigration Status or Citizenship?*
(Proof of citizenship or immigration status will be required upon employment)

Have you worked for this company before?*
If you answered YES to the question above, please provide the following information:
Where? blanks
Dates: From   Date   to   Date
Supervisor:      Position:
Reason for Leaving:

Are you now employed?*
If you answered NO to the question above, how long since leaving your last employment?

Who referred you?
Rate of pay expected?
On what date would you be available for work?*

MonthDay Year
Date
Are you available to work . . .*

Full TimePart TimeDaysNightsWeekends

Have you ever been convicted of a felony?*
* If you reside in or are applying for a position in a jurisdiction that does not permit this inquiry, please select that option. ** Conviction will not necessarily disqualify an applicant from employment.
If you answered YES to the question above, please explain

EDUCATION HISTORY
HIGH SCHOOL
Name of School
City      State
Course/Major      Years Completed
Diploma/Degree      Date   Date
COLLEGE
Name of School
City      State
Course/Major      Years Completed
Diploma/Degree      Date   Date
OTHER (Specify)
Name of School
City      State
Course/Major      Years Completed
Diploma/Degree      Date   Date
Do you speak, read, and/or write any foreign languages (other than English)?
Please identify all foreign languages that you speak, read, and/or write.
Have you received any job-related training in the United States Military?
Please describe any job-related training you received in the United States Military.
Describe any specialized training, apprenticeship, skills and extra-curricular activities:

ADDITIONAL INFORMATION
Other Qualifications
List professional, trade, business or civic activities and offices held:
(You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status)
Summarize special job-related skills and qualifications acquired from employment or other experience.
Specialized Skills

PC10 KeyFaxMS ExcelMS WordMS PowerpointMS PublisherMS Project
Production/Mobile Machinery (list)
Other (list)
State any additional information you feel may be helpful to us in considering your application.

Note to Applicants

IF YOU HAVE NOT BEEN INFORMED OF THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING, SELECT THAT OPTION BELOW.
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?*

HAVE YOU EVER BEEN EMPLOYED BY ANYONE ?*
If you have EVER been employed or held any job with anyone before applying for this position, you must answer YES and provide your employment history in the fields below.

EMPLOYMENT HISTORY

Please provide the following information of all employers. List the past five years of employers in reverse order starting with the most recent. Use additional sheets if necessary. QUESTIONS A, B & C APPLY TO DRIVER POSITIONS ONLY: Applicants for commercial driving positions shall provide ten (10) years of information on those employers for whom the applicant operated a commercial motor vehicle whether in intrastate or interstate commerce. *Any gaps in employment and/or unemployment must be explained. **The Federal Motor Carrier Safety Regulations apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver) for compensation; or (3) is designed or used to transport more than 15 passengers, including the driver, and is not used to transport passengers for compensation; or (4) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
CURRENT OR LAST EMPLOYER

*ALL APPLICANTS - YOU MUST PROVIDE AT LEAST 3 YEARS OF EMPLOYMENT HISTORY, UNLESS YOU HAVE NOT BEEN EMPLOYED FOR THAT LONG.

*CDL DRIVER APPLICANTS - YOU MUST PROVIDE AT LEAST 10 YEARS OF EMPLOYMENT HISTORY, UNLESS YOU HAVE NOT BEEN EMPLOYED FOR THAT LONG.

IF YOU DO NOT HAVE ANY EMPLOYMENT HISOTRY, TYPE "N/A" OR "NONE" IN THE REQUIRED (*) FIELDS BELOW

Employer's Name   *
Employer's Street Address   *
City   *
State   *   Zip   *
Contact Person   *
Phone Number   *
Dates of Employment From   Start Date   To   End Date
Position Held   *   Salary/Wage   *
Reason for Leaving   *

A. Account for Period between jobs-include dates (Month/Year) Reason*
B. Were you subject to the Federal Motor Carrier Safety Regulations ** While Employed?   *
C. Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the Drug and Alcohol Testing Requirements?   *

CLICK "NEXT" TO ADD AN ADDITIONAL EMPLOYER

SECOND EMPLOYER

(Click "Next" if you do not have another employer to add)

Name
Address
City
State      Zip
Contact Person
Phone Number
Dates of Employment: From   Date   to   Date
Position Held      Salary/Wage
Reason for Leaving

A. Account for Period between jobs-include dates (Month/Year) Reason
B. Were you subject to the Federal Motor Carrier Safety Regulations ** While Employed?
C. Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the Drug and Alcohol Testing Requirements?

THIRD EMPLOYER

(Click "Next" if you do not have another employer to add)

Name      Address      City
State      Zip      Contact Person
Phone Number
Dates of Employment: From   Date   to   Date
Position Held      Salary/Wage
Reason for Leaving

A. Account for Period between jobs-include dates (Month/Year) Reason
B. Were you subject to the Federal Motor Carrier Safety Regulations ** While Employed?
C. Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the Drug and Alcohol Testing Requirements?

FOURTH EMPLOYER

(Click "Next" if you do not have another employer to add)

Name      Address      City
State      Zip      Contact Person
Phone Number
Dates of Employment: From   Date   to   Date
Position Held      Salary/Wage
Reason for Leaving

A. Account for Period between jobs-include dates (Month/Year) Reason
B. Were you subject to the Federal Motor Carrier Safety Regulations ** While Employed?
C. Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the Drug and Alcohol Testing Requirements?

FIFTH EMPLOYER

(Click "Next" if you do not have another employer to add)

Name      Address      City
State      Zip      Contact Person
Phone Number
Dates of Employment: From   Date   to   Date
Position Held      Salary/Wage
Reason for Leaving

A. Account for Period between jobs-include dates (Month/Year) Reason
B. Were you subject to the Federal Motor Carrier Safety Regulations ** While Employed?
C. Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the Drug and Alcohol Testing Requirements?

SIXTH EMPLOYER

(Click "Next" if you do not have another employer to add)

Name      Address      City
State      Zip      Contact Person
Phone Number
Dates of Employment: From   Date   to   Date
Position Held      Salary/Wage
Reason for Leaving

A. Account for Period between jobs-include dates (Month/Year) Reason
B. Were you subject to the Federal Motor Carrier Safety Regulations ** While Employed?
C. Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the Drug and Alcohol Testing Requirements?

SEVENTH EMPLOYER

(Click "Next" if you do not have another employer to add)

Name      Address      City
State      Zip      Contact Person
Phone Number
Dates of Employment: From   Date   to   Date
Position Held      Salary/Wage
Reason for Leaving

A. Account for Period between jobs-include dates (Month/Year) Reason
B. Were you subject to the Federal Motor Carrier Safety Regulations ** While Employed?
C. Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the Drug and Alcohol Testing Requirements?

EIGHTH EMPLOYER

(Click "Next" if you do not have another employer to add)

Name      Address      City
State      Zip      Contact Person
Phone Number
Dates of Employment: From   Date   to   Date
Position Held      Salary/Wage
Reason for Leaving

A. Account for Period between jobs-include dates (Month/Year) Reason
B. Were you subject to the Federal Motor Carrier Safety Regulations ** While Employed?
C. Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the Drug and Alcohol Testing Requirements?

REFERENCES
Name *
Contact Information (E-Mail, Telephone, or Address) *
Name
Contact Information (E-Mail, Telephone, or Address)
Name
Contact Information (E-Mail, Telephone, or Address)

I certify that this application was completed by me and that entries on it and information in it are true and complete to the best of my knowledge. I further understand that the information provided herein may be used by Cheney Brothers, Inc. to contact prior employers & investigate my background.*

Clear
Date*

MonthDay Year
NON-CDL DRIVERS - YOUR APPLICATION IS COMPLETE

PLEASE CLICK NEXT UNTIL YOU CAN SUBMIT THE APPLICATION
CDL DRIVER APPLICANTS - PLEASE CONTINUE

WE ARE REQUIRED TO OBTAIN ADDITIONAL INFORMATION FOR ALL CDL DRIVERS.

Complete this section only if you have a Class "A" or "B" License and you are applying for a commercial driving position.
Drivers Licenses

LIST ALL LICENSES HELD IN LAST THREE YEARS
State      License No.
Endorsements      Type
Expiration   Date
Have you held any other licenses in the last 3 years?
State      License No.
Endorsements      Type
Expiration   Date
Have you held any other licenses in the last 3 years?
State      License No.
Endorsements      Type
Expiration   Date
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?
B. Has any license, permit or privilege ever been suspended or revoked
IF THE ANSWER TO EITHER A OR B IS YES, ATTACH STATEMENT GIVING DETAILS

Driving Experience
Do you have driving experience?
Class of Equipment
Type of Equipment (Van, Tank, Flat, Etc.)
Dates: From   Date   to   Date
Approx. No. of Miles (Total)
Do you have additional driving experience?
Class of Equipment
Type of Equipment (Van, Tank, Flat, Etc.)
Dates: From   Date   to   Date
Approx. No. of Miles (Total)
Do you have additional driving experience?
Class of Equipment
Type of Equipment (Van, Tank, Flat, Etc.)
Dates: From   Date   to   Date
Approx. No. of Miles (Total)
Do you have additional driving experience?
Class of Equipment
Type of Equipment (Van, Tank, Flat, Etc.)
Dates: From   Date   to   Date
Approx. No. of Miles (Total)
A. LIST STATES OPERATED IN FOR THE LAST FIVE YEARS:
B. SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER:
C. WHICH SAFE DRIVING AWARDS TO YOU HOLD AND FROM WHOM?

ACCIDENT RECORD FOR PAST 3 YEARS

* List ALL accidents regardless of citation or charges and regardless of whether received in personal or commercial vehicle
Have you had any accidents (regardless of citations or charges) in any commercial or personal vehicle in the past 3 years?
If you answered YES to this question, please list ALL such accidents.
Class of Equipment
Nature of Accident (Head-on, Rear-end, Upset, Etc.)
Date:   Date
Fatalities:
Injuries:
Class of Equipment
Nature of Accident (Head-on, Rear-end, Upset, Etc.)
Date:   Date
Fatalities:
Injuries:
Class of Equipment
Nature of Accident (Head-on, Rear-end, Upset, Etc.)
Date:   Date
Fatalities:
Injuries:
Class of Equipment
Nature of Accident (Head-on, Rear-end, Upset, Etc.)
Date:   Date
Fatalities:
Injuries:

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)

* List ALL traffic convictions and forfeitures regardless of whether received in personal or commercial vehicle
Have you had any traffic convictions and/or forfeitures in the past 3 years in a commercial or personal vehicle?
If you answered YES to this question, please list ALL such convictions or forfeitures.
Location Date Date
Charge Penalty
Location Date Date
Charge Penalty
Location Date Date
Charge Penalty
Use additional paper if more space is needed.

EXPERIENCE AND QUALIFICATIONS - OTHER
Show any trucking, transportation or other experience that may help in your work for this company:
List courses and training other than show elsewhere in this application:
List special equipment or technical materials you can work with (other than those already listed):

Have you registered with the FMCSA Drug & Alcohol Clearinghouse?
If you answered "No" or "I Don't Know", please immediately visit http://clearinghouse.fmcsa.dot.gov and register and/or confirm your registration.

SIGNATURE PAGE FOR CDL DRIVER APPLICANTS ONLY

SELECT "NEXT" TO SUBMIT YOUR APPLICATION
Date

MonthDay Year
I certify that this driver's application was completed by me and that entries on it and information in it are true and complete to the best of my knowledge. I further understand that the information provided herein may be used by Cheney Brothers, Inc. to contact prior employers and investigate my background.

Clear

PLEASE CLICK "SUBMIT" BELOW AND THEN CLICK ON THE LINK THAT FOLLOWS TO COMPLETE ALL OF THE FORMS REQUIRED TO PROCESS YOUR APPLICATION
Should be Empty:

APPLICATION FOR EMPLOYMENT

EDUCATION HISTORY

ADDITIONAL INFORMATION

Other Qualifications

Note to Applicants

EMPLOYMENT HISTORY

REFERENCES

NON-CDL DRIVERS - YOUR APPLICATION IS COMPLETE

CDL DRIVER APPLICANTS - PLEASE CONTINUE

Complete this section only if you have a Class "A" or "B" License and you are applying for a commercial driving position.

Drivers Licenses

Driving Experience

ACCIDENT RECORD FOR PAST 3 YEARS

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)

Use additional paper if more space is needed.

EXPERIENCE AND QUALIFICATIONS - OTHER

SIGNATURE PAGE FOR CDL DRIVER APPLICANTS ONLY

PLEASE CLICK "SUBMIT" BELOW AND THEN CLICK ON THE LINK THAT FOLLOWS TO COMPLETE ALL OF THE FORMS REQUIRED TO PROCESS YOUR APPLICATION