Personal Information
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Name:
Phone:
Format: (000) 000-0000.
Address:
If selected, are you willing to submit to a background check?
Available Start Date:
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Expected Wage:
Driver's License Information
Driver's License Information
Rows
License Number
Class
Endorsements
Exp Date
1.
2.
3.
Do you have any experience operating trucks?
YES
NO
If yes, list types of trucks drive:
Have you ever pled guilty or no contest to a felony?
YES
NO
Explain the details:
Have you ever been convicted or pled guilty or no contest to a DWI/DUI or any alcohol or drug related offense?
YES
NO
If yes, when?
(If yes, please give details in traffic violation information, page 3)
Have you ever tested positive on alcohol or controlled substance test?
YES
NO
Have you refused to be tested for alcohol, controlled substance in the last 3 years?
YES
NO
Are you authorized to work in the United States?
YES
NO
Are you able to pass a DOT Physical?
YES
NO
Do you take any medications that could affect your ability to safely drive a vehicle?
YES
NO
Has your license ever been denied, revoked, canceled or suspended?
YES
NO
(If yes, please explain on a separate sheet of paper.)
Have you served in the U.S. Armed Forces?
YES
NO
Have you ever worked or applied for Gulf States Industrial Diesel?
YES
NO
How did you hear about Gulf States Industrial Diesel?
Are you currently related to anyone employed with Gulf States Industrial Diesel?
YES
NO
Are you presently employed?
YES
NO
If yes, may we contact your current employer?
YES
NO
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Employment History
List all periods of employment (full and part-time), self-employment, unemployment, and schooling during the past ten (10) years, beginning with the most recent time period. If unemployed for over 30 days, provide means of verification (names, telephone numbers, documents, etc.) Any application received that is incomplete WILL NOT BE PROCESSED.
Employer- (past 10 years starting with most recent)
Rows
Name Company
Address
Start Date
End Date
Starting Pay
Ending Pay
Job Title
1. Employer
2. Employer
3. Employer
4. Employer
5. Employer
Reason for Leaving (1. Employer)
Were you subject to the federal Motor Carrier Safety Regulations (FMCSRs) while employed with this company? (1. Employer)
YES
NO
Was your job designated as a safety sensitive function in any DOT regulation mode subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40? (1. Employer)
YES
NO
Reason for Leaving
Were you subject to the federal Motor Carrier Safety Regulations (FMCSRs) while employed with this company? (2. Employer)
YES
NO
Was your job designated as a safety sensitive function in any DOT regulation mode subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40? (2. Employer)
YES
NO
Reason for Leaving (3. Employer)
Were you subject to the federal Motor Carrier Safety Regulations (FMCSRs) while employed with this company? (3. Employer)
YES
NO
Was your job designated as a safety sensitive function in any DOT regulation mode subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40? (3. Employer)
YES
NO
Reason for Leaving (4. Employer)
Were you subject to the federal Motor Carrier Safety Regulations (FMCSRs) while employed with this company? (4. Employer)
YES
NO
Was your job designated as a safety sensitive function in any DOT regulation mode subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40? (4. Employer)
YES
NO
Reason for Leaving (5. Employer)
Were you subject to the federal Motor Carrier Safety Regulations (FMCSRs) while employed with this company? (5. Employer)
YES
NO
Was your job designated as a safety sensitive function in any DOT regulation mode subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40? (5. Employer)
YES
NO
References
References- (if any)
Rows
Name
Company
Title
Phone
Reference 1
Reference 2
Reference 3
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