APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT
NAME
FIRST
MIDDLE
Maiden Name if any
LAST
ADDRESS
STREET
CITY
STATE, ZIP CODE
HOW LONG
DATE OF BIRTH

MonthDayYear
Date
SOCIAL SECURITY NO
HIRE DATE

MonthDayYear
Date
PHONE NUMBER
Format: (000) 000-0000.
EMAIL
example@example.com
PREVIOUS THREE YEARS RESIDENCY
STREET
CITY
STATE, ZIP CODE
YEARS
STREET
CITY
STATE, ZIP CODE
YEARS
STREET
CITY
STATE, ZIP CODE
YEARS
LICENSE INFORMATION
Section 383.21 FMCSR states "No person who operates a commercial motor vehicle shall at any time have more than one driver's license." I certify that I do not have more than one motor vehicle license, the information for which is listed below.
STATE
LICENSE NO
TYPE
EXPIRATION DATE

MonthDayYear
Date
DRIVING EXPERIENCE
Straight Truck
Type of Equipment (Van, Tank, Flat, ETC.)
Date From To
Approx. No. Miles (Total)
Tractor & Simi-Trailer
Type of Equipment (Van, Tank, Flat, ETC.)
Date From To
Approx. No. Miles (Total)
Tractor - Two Trailers
Type of Equipment (Van, Tank, Flat, ETC.)
Date From To
Approx. No. Miles (Total)
Other
Type of Equipment (Van, Tank, Flat, ETC.)
Date From To
Approx. No. Miles (Total)
ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE NEEDED)
Date
Nature of Accident
(Head-On, Rear, Upset, ETC)
Number Fatalities
Number Injuries
Chemical Spills

YesNo
Date
Nature of Accident
(Head-On, Rear, Upset, ETC)
Number Fatalities
Number Injuries
Chemical Spills

YesNo
Date
Nature of Accident
(Head-On, Rear, Upset, ETC)
Number Fatalities
Number Injuries
Chemical Spills

YesNo
TRAFFIC CONVICTIONS & FORFEITURES FOR THE PAST 3 YEARS

(Other than Parking Violations)
Date Convicted
Month/Year
Violation
State of Violation Location
Penalty
forfeited bond, collateral and/or points
Date Convicted
Month/Year
Violation
State of Violation Location
Penalty
forfeited bond, collateral and/or points
Date Convicted
Month/Year
Violation
State of Violation Location
Penalty
forfeited bond, collateral and/or points
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?

YesNo
If yes explain
B. Has any license, permit or privilege ever been suspended or revoked?

YesNo
If yes explain
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
ADDRESS
PHONE
Format: (000) 000-0000.
POSITION HELD
FROM
TO
SALARY
REASONS FOR LEAVING
ANY GAPS IN EMPLOYMENT ANDOR UNEMPLOYMENT MUST BE EXPLAINED INCLUDE DATES MONTHYEAR AND REASON

MonthDayYear
Date
Were you subject to Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?

YesNo
Was the previous job position designated as a safety sensitive function in and DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?

YesNo
SECOND LAST EMPLOYER
ADDRESS
PHONE
Format: (000) 000-0000.
POSITION HELD
FROM
TO
SALARY
REASONS FOR LEAVING
ANY GAPS IN EMPLOYMENT ANDOR UNEMPLOYMENT MUST BE EXPLAINED INCLUDE DATES MONTHYEAR AND REASON

MonthDayYear
Date
Were you subject to Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?

YesNo
Was the previous job position designated as a safety sensitive function in and DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?

YesNo
THIRD LAST EMPLOYER
ADDRESS
PHONE
Format: (000) 000-0000.
POSITION HELD
FROM
TO
SALARY
REASONS FOR LEAVING
ANY GAPS IN EMPLOYMENT ANDOR UNEMPLOYMENT MUST BE EXPLAINED INCLUDE DATES MONTHYEAR AND REASON

MonthDayYear
Date
Were you subject to Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?

YesNo
Was the previous job position designated as a safety sensitive function in and DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?

YesNo
TO BE READ AND SIGNED BY APPLICANT
I authorize you to make sure investigations and inquires to my personal, employment, financial or medical history and other related matters as may be necessary inarriving at the employment decision. (generally, inquires regarding medical history will be made only if and after conditional offer of employment has been extended I hereby release employers, schools, health care providers and other persons from all liability in responding to inquired 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 contracted, 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 previouse employers to re-send the corrected informations to the prospective employers; 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
APPLICANTS SIGNATURE
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
APPLICANTS SIGNATURE
Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations
Lie Detector Tests: Article 100, Section 95, Annotated Code of Maryland: "Under Maryland law an employer may not require or demand any applicant for employment or prospective employment or any employee to submit to or take a polygraph, lie detector or similar test or examination as a condition of employ- ment or continued employment. Any similar test or examination as a condition of employment or continued employment. Any employer who ciolates this provision is guilty of a misdemeanor and subject to a fine not to exceed $100."
DATE

MonthDayYear
Date
APPLICANTS SIGNATURE
Corbin Fuel Company, Inc. does not discriminate on the basis of race, color, sex, age, national origin, religion, or disability in matters affecting employment or in providing access to programs.
Should be Empty:

APPLICATION FOR EMPLOYMENT

NAME

ADDRESS

PREVIOUS THREE YEARS RESIDENCY

LICENSE INFORMATION

DRIVING EXPERIENCE

Straight Truck

Tractor & Simi-Trailer

Tractor - Two Trailers

Other

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE NEEDED)

TRAFFIC CONVICTIONS & FORFEITURES FOR THE PAST 3 YEARS

TO BE READ AND SIGNED BY APPLICANT