DRIVER'S APPLICATION FOR EMPLOYMENT

DRIVER'S APPLICATION FOR EMPLOYMENT

Reliant Tank Division, Inc.
Applicant Name*

First NameLast Name
Date of Application*

MonthDayYear
Email Address*

Confirmation Emailexample@example.com
Company*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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, veteran status, non-job related disability, or any other protected group status.
TO BE READ AND SIGNED BY APPLICANT
I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history andother 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 releasinginformation 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 I have the right to:
- Review information provided by 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.
Applicant's Signature

Clear
Date

MonthDayYear
FOR COMPANY USE
PROCESS RECORD
(IF REJECTED, SUMMARY REPORT OF REASONS SHOULD BE PLACED IN FILE)
Signature of interviewing officer

Clear
TERMINATION OF EMPLOYMENT
Date

MonthDayYear
Date
Department Released from
DismissedVoluntarily QuitOther
Termination Report Placed in file
Supervisor
This form is made available with the understanding that J. J. Keller & Associates, Inc.® is not engaged in rendering legal, accounting, or other professional services. J. J. Keller & Associates, Inc.® assumes no responsibility for the use of this form or any decision made by an employer which may violate local, state or federal law.

APPLICANT TO COMPLETE

(Answer all questions - Please print)
Position(s) Applied for*
Name*

First NameMiddle NameLast Name
Social Security Number
List your addresses of residency for the past 3 years.
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
How long?*
yr./mo.
Previous Address (1)

Street Address

Street Address Line 2

CityState & Zip Code

Postal / Zip Code
How long?
yr./mo.
Previous Address (2)

Street Address

Street Address Line 2

CityState & Zip Code

Postal / Zip Code
How long?
yr./mo.
Previous Address (3)

Street Address

Street Address Line 2

CityState & Zip Code

Postal / Zip Code
How long?
yr./mo.
Do you have the legal right to work in the United States?*
Date of Birth*

MonthDayYear
(Required for Commerical Drivers)
Can you provide proof of age?*
Have you worked for this company before? *
Where?
Dates
From - To
Rate of Pay
Position
Reason for leaving
Are you now employed?*

YesNo
If not, how long since leaving last employment?
Who referred you?
Rate of pay expected
Have you ever been bonded? (Answer only if a job requirement)*

YesNo
Name of Bonding company
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]?
If yes, explain if you wish

ACCIDENT RECORD
FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED) IF NONE, WRITE NONE
Last Accident
Date
Nature of Accident (Head-on, Rear-end, Upset, etc.)
Fatalities
Injuries
Hazardous Material Spill
Next Previous Accident
Date
Nature of Accident (Head-on, Rear-end, Upset, etc.)
Fatalities
Injuries
Hazardous Material Spill
Next Previous Accident
Date
Nature of Accident (Head-on, Rear-end, Upset, etc.)
Fatalities
Injuries
Hazardous Material Spill

TRAFFIC CONVICTIONS
AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE
Traffic Conviction (1)
Traffic Conviction (2)
Traffic Conviction (3)

EXPERIENCE AND QUALIFICATIONS - DRIVER

Driver licenses or permits held in the past 3 years
Driver license / permit (1)*
Driver license / permit (2)
Driver license / permit (3)
Driver license / permit (4)
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
TRACTOR AND SEMI-TRAILER
TRACTOR - TWO TRAILERS
TRACTOR - THREE TRAILERS
MOTORCOACH - SCHOOL BUS (more than 8 passengers)
MOTORCOACH - SCHOOL BUS (more than 15 passengers)
Other (add row below if necessary)
LIST STATES OPERATED IN FOR THE LAST FIVE YEARS:
SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER:
WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM?
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 SHOWN ELSEWHERE IN THIS APPLICATION:
LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN):

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
Should be Empty:

DRIVER'S APPLICATION FOR EMPLOYMENT

TO BE READ AND SIGNED BY APPLICANT

FOR COMPANY USE

APPLICANT TO COMPLETE

EMPLOYMENT HISTORY

Employer (1)

Employer (2)

Employer (3)

ACCIDENT RECORD

Last Accident

Next Previous Accident

Next Previous Accident

TRAFFIC CONVICTIONS

EXPERIENCE AND QUALIFICATIONS - DRIVER

DRIVING EXPERIENCE

EXPERIENCE AND QUALIFICATIONS - OTHER

EDUCATION

TO BE READ AND SIGNED BY APPLICANT