Industrial Resourcing - Drivers Application For Employment

Drivers Application For Employment

In compliance with Federal and State equal employment laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.
Name*

First NameLast Name
Date of Application*

MonthDayYear
Date
To Be Read and Signed by Applicant
I authorize you to make such investigations and inquiries on 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.*

Yes, I authorize this.
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.*

Yes, I authorize this.
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 my 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.*

Yes, I authorize this.
Applicant To Complete

Please answer all questions.
Position(s) Applied For*
Name*

First NameMiddle NameLast Name
Social Security Number*
Home Phone
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Email*
example@example.com
Addresses

List your addresses of residency for the past 3 years:
Current Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Current Address Length of Stay:*
Previous Address 1:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Previous Address 1 Length of Stay:
Previous Address 2:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Previous Address 2 Length of Stay:
Do you have the right to work in the United States?*

YesNo
Date of Birth*

MonthDayYear
Required for Commercial Drivers
Can you provide proof of age?*

YesNo
Have you worked for LSPM or INDUSTRIAL RESOURCING?*

YesNo
From

MonthDayYear
Date
To

MonthDayYear
Date
Rate of Pay
Position
Have you ever been bonded? (Answer only if a job requirement):

YesNo
Name of Bonding Company:
Have you ever been convicted of a felony?*

YesNo
If yes, please explain here.
Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the attached job description)?*

YesNo
If yes, explain if you wish:
Employment History

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. Please list complete mailing address, street number, city, state and zip code. Applicants to driver a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years' information on those employers for whom the applicant operated such vehicle. (Note: List employers in reverse order starting with the most recent.)
Employer
Employment Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
From:

MonthDayYear
Date
To:

MonthDayYear
Date
Contact Person

First NameLast Name
Contact Phone Number
Position Held:
Salary/Wage:
Reason for Leaving:
Where you subject to the FMCSRs** while employed?

YesNo
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

YesNo
Employer
Employment Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
From:

MonthDayYear
Date
To:

MonthDayYear
Date
Contact Person

First NameLast Name
Contact Phone Number
Position Held:
Salary/Wage:
Reason for Leaving:
Where you subject to the FMCSRs** while employed?

YesNo
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

YesNo
Employer
Employment Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
From:

MonthDayYear
Date
To:

MonthDayYear
Date
Contact Person

First NameLast Name
Contact Phone Number
Position Held:
Salary/Wage:
Reason for Leaving:
Where you subject to the FMCSRs** while employed?

YesNo
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

YesNo
Employer
Employment Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
From:

MonthDayYear
Date
To:

MonthDayYear
Date
Contact Person

First NameLast Name
Contact Phone Number
Position Held:
Salary/Wage:
Reason for Leaving:
Where you subject to the FMCSRs** while employed?

YesNo
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

YesNo
Employer
Employment Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
From:

MonthDayYear
Date
To:

MonthDayYear
Date
Contact Person

First NameLast Name
Contact Phone Number
Position Held:
Salary/Wage:
Reason for Leaving:
Where you subject to the FMCSRs** while employed?

YesNo
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

YesNo
Employer
Employment Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
From:

MonthDayYear
Date
To:

MonthDayYear
Date
Contact Person

First NameLast Name
Contact Phone Number
Position Held:
Salary/Wage:
Reason for Leaving:
Where you subject to the FMCSRs** while employed?

YesNo
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

YesNo
Employer
Employment Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
From:

MonthDayYear
Date
To:

MonthDayYear
Date
Contact Person

First NameLast Name
Contact Phone Number
Position Held:
Salary/Wage:
Reason for Leaving:
Where you subject to the FMCSRs** while employed?

YesNo
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

YesNo
Employer
Employment Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
From:

MonthDayYear
Date
To:

MonthDayYear
Date
Contact Person

First NameLast Name
Contact Phone Number
Position Held:
Salary/Wage:
Reason for Leaving:
Where you subject to the FMCSRs** while employed?

YesNo
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

YesNo
* Includes vehicles having a GVWR of 26,001 lbs or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

** 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 lbs or more, (2) is designed or used to transport 8 or more passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
Accident Record

For past 3 years or more (write below if more space is needed.) If none, write none.
Last Accident
None
Next Previous
Next Previous
Traffic Convictions

and forfeitures for the past 3 years(other thann parking violations.) If none, write none.
Traffic Convictions
None
Experience and Qualifications-Driver

Include all driver licenses or permits held in the past 3 years
Driver Licenses or Permits*
Driver Licenses or Permits
Driver Licenses or Permits
Driver Licenses or Permits
A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle?*

YesNo
B. Has any license, permit or privilege ever been suspended or revoked?*

YesNo
If the answer to either A or B is yes, give details.
Driving Experience

Check Yes or No
Straight Truck

YesNo
Type of Equipment

VanTankFlatDumpRefer
From

MonthDayYear
Date
To

MonthDayYear
Date
Approximate number of miles (total)
Tractor and Semi Trailer

YesNo
Type of Equipment

VanTankFlatDumpRefer
From

MonthDayYear
Date
To

MonthDayYear
Date
Approximate number of miles (total)
Tractor + Two Trailers

YesNo
Type of Equipment

VanTankFlatDumpRefer
From

MonthDayYear
Date
To

MonthDayYear
Date
Approximate number of miles (total)
Tractor+ Three Trailers

YesNo
Type of Equipment

VanTankFlatDumpRefer
From

MonthDayYear
Date
To

MonthDayYear
Date
Approximate number of miles (total)
Motor Coach + School Bus (more than 8 passengers)

YesNo
From

MonthDayYear
Date
To

MonthDayYear
Date
Approximate number of miles (total)
Motor Coach + School Bus (more than 15 passengers)

YesNo
From

MonthDayYear
Date
To

MonthDayYear
Date
Approximate number of miles (total)
Other
From

MonthDayYear
Date
To

MonthDayYear
Date
Approximate number of miles (total)
List states operated in for last five years:
Show special courses or training that will help you as a driver:
Experience and Qualifications - Other
Show any trucking, transportation or other experience that may help you in your work for this company:
List courses and training other than shown elsewhere in this application:
List special equipment or technical materials you can work with (other than those already shown):
Education
Highest grade completed:
High School:
College:
Last school attended:
To be Read and Signed by Applicant

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.
Signature

Clear
Date

MonthDayYear
Date

Drivers Application For Employment

To Be Read and Signed by Applicant

Applicant To Complete

Addresses

Employment History

Accident Record

Traffic Convictions

Experience and Qualifications-Driver

Driving Experience

Experience and Qualifications - Other

Education

To be Read and Signed by Applicant

This Section (For Company Use Only)