Big E Services, LLC Employment Application

Big E Services, LLC

Employment Application Form
Today's Date*

MonthDayYear
Date
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long at current address?*
Date of Birth*

MonthDayYear
Date
SSN*
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Driver's License #*
Date of Expiration*

MonthDayYear
Date
Endorsements (type NA if not applicable)*
Are you under the age of 18?*

YesNo
if "YES", can you provide proof of your eligibility to work?*

YesNo
Are you currently authorized to work in the United States? (Proof of eligibility will be required if hired.)*

YesNo
Position applied for*
Wage desired*
Days/hours available to work*

No preferenceMondayTuesdayWednesdayThursdayFridaySaturdaySunday
How many hours can you work weekly?*
Employment desired*

Full-Time OnlyPart-Time OnlyTemporary/Contract
When are you available to start work?*

Type of School (type NA if not applicable)*

	Name of School	Location	Number of Years Completed	Major & Degree
High School
GED
Bus. or Trade School
Professional School

Have you ever been convicted of a crime? (A conviction record will not necessarily disqualify you from employment.)*

YesNo
How were you referred to the company? (ie. newspaper ad, radio, company employee)*
If employee referral, employee's name.*

PLEASE READ CAREFULLY
I hereby authorize the potential employer to contact, obtain, and verify the accuracy of information contained in this application from all previous employers, educational institutions, and references. I also hereby release from liability the potential employer and its representatives for seeking, gathering, and using such information to make employment decisions and all other persons or organizations for providing such information.

I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered.

If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either I or the employer can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law.

We are an equal opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, gender, sexual orientation, national origin, citizenship, age, height, weight, or disability. We assure you that your opportunity for employment with us depends solely on your qualifications.

Thank you for completing this application form and for your interest in our business.
Signature*

Clear
Print*
Date*

MonthDayYear
Date

Employment Record

(Attach sheet if more space is needed)
Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record).

Must list the complete mailing address: street number and name, city, state and zip code.
Last Employer: Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Salary
Reasons for leaving
Second Last Employer: Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Position Held
From: Date To: Date
Salary
Reasons for leaving
Third Last Employer: Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Position Held
From: Date To: Date
Salary
Reasons for leaving
TO BE READ AND SIGNED BY APPLICANT

I authorize you to make sure investigations and inquiries to my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding 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 understand, also, that I am required to abide by all rules and regulations of the Company.

"I understand that information I provide regarding current and/or previous 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(d) and (e). I understand that I have the right to:
- Review information provided by current/previous employers;
- Have errors in the information corrected by previous employers and for those previous employers to re-send 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."
Date*

MonthDayYear
Date
Signature*

Clear
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.
Date*

MonthDayYear
Date
Signature*

Clear
Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.

	Type of Equipment (Van, Tank, Flat, Etc.)	Dates From To	Approx No. of Miles (Total)
Straight Truck
Tractor and Semi-Trailer
Tractor - Two Trailers
Other

	Dates (month/year)	Nature of Accident (Head-On, Rear-End, Upset, Etc.)	Number Fatalities	Number Injuries	Chemical Spills (Y/N)
1
2
3

	Date Convicted (month/year)	Violation	State of Violation	Penalty (forfeited bond, collateral and/or points)
1
2
3

Big E Services, LLC

Military

Work Experience

PLEASE READ CAREFULLY

Employment Record

BIG E SERVICES, LLC

Previous Three Years Residency

License Information