In-Home Contractor Application

IN-HOME CONTRACTOR APPLICATION
In compliance with Federal and State Equal Employment Opportunity laws, qualified applicants are considered for all positions without regard to race, color religion, sex, national origin, age, marital status, or non-job-related disability.
Answer all questions completely – Please Print
Date of Application:

MonthDayYear
Date
Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date
Social Security #
Drivers License #:
State:
Home Phone:
Please enter a valid phone number.
Cell Phone:
Please enter a valid phone number.
Current Address:

Street Address

Street Address Line 2

CityState

Zip Code
How Long at Current Address?
(If less than 5 years, please list previous address)
Previous Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-Mail Address:
Are you currently employed?
If not, how long since leaving employment?
Why?
Who referred you?
Rate of pay expected?
Do you have the legal right to work in the United States?
Have you ever worked for this company before?
Dates: From:

MonthDayYear
Date
To:

MonthDayYear
Date
Position:
If so, reason for leaving:
Is there any reason you might be unable to perform the functions of the job for which you have applied? If yes, please explain:

Employment History/Business History

(NOTE: List employers in reverse order starting with the most recent. Add additional sheets as necessary.)
Employer:
From:
To:
Address:

Street Address

Street Address Line 2

City:State:

Zip Code:
Phone #:
Please enter a valid phone number.
Fax #:
Contact Person:
Position Held:
Salary / Wage:
Reason for Leaving:
Duties Performed:
Employer:
From:
To:
Address:

Street Address

Street Address Line 2

City:State:

Zip Code:
Phone #:
Please enter a valid phone number.
Fax #:
Contact Person:
Position Held:
Salary / Wage:
Reason for Leaving:
Duties Performed:
Employer:
From:
To:
Address:

Street Address

Street Address Line 2

City:State:

Zip Code:
Phone #:
Please enter a valid phone number.
Fax #
Contact Person:
Position Held:
Salary / Wage:
Reason for Leaving:
Duties Performed:
†The Federal Motor Carrier Safety Regulations (FMCSRs) 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), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

Additional Employment History/Business History
Employer:
From:
To:
Address:

Street Address

Street Address Line 2

City:State:

Zip Code:
Phone #:
Please enter a valid phone number.
Fax #
Contact Person:
Position Held:
Reason for Leaving:
Salary / Wage:
Duties Performed:
Employer:
From:
To:
Address:

Street Address

Street Address Line 2

City:State:

Zip Code:
Phone #:
Please enter a valid phone number.
Fax #
Contact Person:
Position Held:
Salary / Wage:
Reason for Leaving:
Duties Performed:
Employer:
From:
To:
Address:

Street Address

Street Address Line 2

City:State:

Zip Code:
Phone #:
Please enter a valid phone number.
Fax #
Contact Person:
Position Held:
Salary / Wage:
Reason for Leaving:
Duties Performed:

Education
Highest Grade Completed:

High School:College:
Other:
(Please include all driving schools):
Last School Attended:

(Name)(City)
Graduation Date

Experience and Qualifications – Drivers

Please List all Drivers Licenses held within the last 3 years:

	State	License No.	Type	Expiration
1
2
3
4

Please List all Accidents for the last 3 years:

	Date	Nature of Accident (Head-On, Rear-End, Upset, etc.)	Injuries or Fatalities?	Est. Cost over $1,000
1
2
3
4
5

Please List all Traffic Convictions and/ or Forfeitures for the past 3 years (other thanparking). If NONE, write NONE:

	Date	Location	Charge	Penalty
1
2
3
4
5

Have you ever been denied a license, permit or privilege to operatea motor vehicle?

YesNo
Please explain
Date:

MonthDayYear
Date
Has any license, permit or privilege ever been suspended orRevoked in the last 5 years?

YesNo
Please explain
Date:

MonthDayYear
Date
Have you ever or are you currently under investigation orarraignment of felony or misdemeanor charge(s)?

YesNo
Please explain
Date:

MonthDayYear
Date
Driving Experience (If NONE, write NONE)

Type

	Type of Equipment (Van, tanker, reefer, flat, etc.)	Dates (From / To)	Appx. Number Of Miles
Straight Truck
Tractor & Semi-Trailer
Tractor & Doubles
Motor Coach– School Bus
Other

List all states operated in for the last 5 years:

DISCLOSURE AND AUTHORIZATION REGARDING BACKGROUND INVESTIGATION FOR CONTRACTING PURPOSES
Disclosure
RAPID RESPONSE, INC. (the “Company”) may request from a consumer reporting agency and for contract-related purposes, a “consumer report(s)” (commonly known as “background reports”) containing background information about you in
connection with your contract (including independent contractor or volunteer assignments, as applicable).

The background report(s) may contain information concerning your character, general reputation, personal characteristics, mode of living, or credit standing. The types of background information that may be obtained include, but are not limited to: criminal history; litigation history; motor vehicle record and accident history; social security number verification; address and alias history; credit history; verification of your education, employment and earnings history; professional licensing, credential and certification checks; drug/alcohol testing results and history; military service; and other information.

Authorization
I hereby authorize Company to obtain the consumer reports described above about me.
Applicant Signature

Clear
Date

MonthDayYear
Date
Printed Name
Date of Birth:

MonthDayYear
Date
Social Security #:
Driver’s License #:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:
Please enter a valid phone number.
Driver's License

***Please provide a copy of your driver’s license with this signed form
Cancelof
Should be Empty:

IN-HOME CONTRACTOR APPLICATION

Employment History/Business History

Additional Employment History/Business History

Education

Experience and Qualifications – Drivers

Driving Experience (If NONE, write NONE)

DISCLOSURE AND AUTHORIZATION REGARDING BACKGROUND INVESTIGATION FOR CONTRACTING PURPOSES