Application For Qualification Monument Truck

APPLICATION FOR QUALIFICATION

Monument Transportation

780 21 1/2 Road

Grand Junction CO 81505

Instructions to Applicant.

Please answer all questions.

Date*

Date

Position applying for:*

Position applying for.

Full Name*

First NameLast Name

Phone Number*

Area CodePhone Number

E-mail*

Age*

Age

Date of Birth*

MonthDayYear

Social Security Number (You may call and give this over the phone)

Social Security Number.

Date CDL was obtained:

CDL Date

Physical Exam Expiration Date:*

Physical Exam Expiration Date

Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Please list prior 3 year addresses here and please be complete*

Prior 3 year addresses.

Have you worked for this company before?*

YesNo

If yes, From date:

Worked for From Date

If yes, To Date:

Worked for To Date

Reason for Leaving:

Worked for Reason for Leaving

Education History:*

Give a Complete Record of all employment for the past three years, including any unemployment or self-employment, and all commercial driving experience for the past ten years.

Employer #1 Start date*

MonthDayYear

Employer #1 Ending date*

MonthDayYear

Employer #1 Present or Last Name*

Present or Last Employer Name #1

Employer #1 Address*

Employer Address #1

Employer #1 phone*

Area CodePhone Number #1

Employer #1 #Position Held*

Position Held #1

Employer #1 Reason for leaving*

Reason for leaving #1

Employer #1 Were you subject to the FMCSRs* while employed here?

YesNo

Employer #1 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

NEXT EMPLOYER (More Employers is better)

Employer #2 Start date

MonthDayYear

Employer #2 Ending date

MonthDayYear

Employer #2 Present or Last Name

Present or Last Employer Name #2

Employer #2 Address

Employer Address #2

Employer #2 phone

Area CodePhone Number #2

Employer #2 #Position Held

Position Held #2

Employer #2 Reason for leaving

Reason for leaving #2

Employer #2 Were you subject to the FMCSRs* while employed here?

YesNo

Employer #2 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

NEXT EMPLOYER (More Employers is better)

Employer #3 Start date

MonthDayYear

Employer #3 Ending date

MonthDayYear

Employer #3 Present or Last Name

Present or Last Employer Name #3

Employer #3 Address

Employer Address #3

Employer #3 phone

Area CodePhone Number #3

Employer #3 #Position Held

Position Held #3

Employer #3 Reason for leaving

Reason for leaving #3

Employer #3 Were you subject to the FMCSRs* while employed here?

YesNo

Employer #3 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

NEXT EMPLOYER (More Employers is better)

Employer #4 Start date

MonthDayYear

Employer #4 Ending date

MonthDayYear

Employer #4 Present or Last Name

Present or Last Employer Name #4

Employer #4 Address

Employer Address #4

Employer #4 phone

Area CodePhone Number #4

Employer #4 #Position Held

Position Held #4

Employer #4 Reason for leaving

Reason for leaving #4

Employer #4 Were you subject to the FMCSRs* while employed here?

YesNo

Employer #4 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

NEXT EMPLOYER (More Employers is better)

Employer #5 Start date

MonthDayYear

Employer #5 Ending date

MonthDayYear

Employer #5 Present or Last Name

Present or Last Employer Name #5

Employer #5 Address

Employer Address #5

Employer #5 phone

Area CodePhone Number #5

Employer #5 #Position Held

Position Held #5

Employer #5 Reason for leaving

Reason for leaving #5

Employer #5 Were you subject to the FMCSRs* while employed here?

YesNo

Employer #5 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

Class: Straight Truck From Date

From Date Straight Truck

Straight Truck To Date:

To Date Straight Truck

Miles: Straight Truck

Straight Truck Miles

Class: Tractor & Semi-Trailer From Date:

From Date Tractor & Semi-Trailer

Tractor & Semi- Trailer To Date:

To Date Tractor & Semi-Trailer

Miles: Tractor & Semi-Trailer

Tractor & Semi-Trailer Miles

Class: Tractor 2 Trailers From Date:

From Date Tractor 2 Trailers

Tractor 2 Trailers To Date:

To Date Tractor 2 Trailers

Miles: Tractor 2 Trailers

Tractor 2 Trailers Miles

Class: Tractor 3 Trailers From Date:

From Date Tractor 3 Trailers

Tractor 3 Trailers To Date:

To Date Tractor 3 Trailers

Miles: Tractor 3 Trailers

Tractor 3 Trailers Miles

Class: Other Description:

Other Description

Class: Other From Date:

From Date Other

Other To Date:

To Date Other

Miles: Other

Other Miles

List states operate in, for the last five years:

States operate in, for the last five years.

List special courses/training completed (PTD?DDC, HAZ MAT, ETC

Special courses/training completed.

List any Safe Driving Awards you hold and from whom:

Safe Driving Awards you hold and from whom.

Accident Record for the past three years (attach sheet if more space is needed)

Date of Accident #1

Nature of Accident (Head On, Rear End, Upset, etc): #1

Nature of Accident #1

Location of Accident #1:

Location of Accident #1

Number of Fatalities #1:

Number of Fatalities #1

Number of People Injured #1:

Number of People Injured #1

NEXT ACCIDENT

Date of Accident #2

Nature of Accident (Head On, Rear End, Upset, etc): #2

Nature of Accident #2

Location of Accident #2:

Location of Accident

Number of Fatalities #2:

Number of Fatalities.

Number of People Injured #2:

Number of People Injured.

NEXT ACCIDENT

Date of Accident #3

Nature of Accident (Head On, Rear End, Upset, etc) #3:

Nature of Accident #3

Location of Accident #3:

Location of Accident #3

Number of Fatalities #3:

Number of Fatalities #3

Number of People Injured #3:

Number of People Injured #3

Traffic Convictions and Forfeitures for the last three years (other than parking viloations)

Date of Conviction #1:

Date of Conviction #1

Location of Conviction #1:

Location of Conviction #1

Charge of Conviction #1:

Charge of Conviction #1

Penalty of Conviction #1:

Penalty of Conviction #1

NEXT CONVICTION

Date of Conviction #2:

Date of Conviction #2

Location of Conviction #2:

Location of Conviction #2

Charge of Conviction #2:

Charge of Conviction #2

Penalty of Conviction #2:

Penalty of Conviction #2

NEXT CONVICTION

Date of Conviction #3:

Date of Conviction #3

Location of Conviction #3:

Location of Conviction #3

Charge of Conviction #3:

Charge of Conviction #3

Penalty of Conviction #3:

Penalty of Conviction #3

Driver's License (list each driver's license held in the past three years)

Drivers License State #1:

Drivers License State #1

License Number #1

License Type #1:

License Type #1

License Endorsements #1:

License Endorsements #1

License Expiration Date #1:

License Expiration Date #1

NEXT LICENSE

Drivers License State #2:

Drivers License State #2

License Number #2:

License Number #2

License Type 2:

License Type #2

License Endorsements #2:

License Endorsements #2

License Expiration Date #2:

License Expiration Date #2

NEXT LICENSE

Drivers License State #3:

Drivers License State #3

License Number #3:

License Number #3

License Type #3:

License Type #3

License Endorsements #3:

License Endorsements #3

License Expiration Date #3:

License Expiration Date #3

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

C. Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the job description)?*

YesNo

D. Have you ever been convicted of a felony?*

YesNo

If the answers to A, B, C or D is "Yes", give details.

Reference #1 Name

Reference #1 Address

Reference #1 Street Address

Reference #1 Street Address Line 2

Reference #1 City Reference #1 State / Province

Reference #1 Postal / Zip CodeReference #1 Country

Reference #1 Phone Number

Area CodePhone Number Reference #1

Reference #1 Number of years known

NEXT Reference (More References is better)

Reference #2 Name

Reference #2 Address

Reference #2 Address Line 2

Reference #2 CityReference #2 State / Province

Reference #2 Postal / Zip CodeReference #2 Country

Reference #2 Phone Number

Area CodePhone Number Reference #2

Reference #2 Number of years known

Reference #2 Number of Years

NEXT Reference (More References is better)

Reference #3 Name

Reference #3 Address

Reference #3 Street Address

Reference #3 Street Address Line 2

Reference #3 CityReference #3 State / Province

Reference #3 Postal / Zip CodeReference #3 Country

Reference #3 Phone Number

Area CodePhone Number Reference #1

Reference #3 Number of years known

Reference #3 Number of Years

It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty. I authorize you to make such investigations and inquiries of 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.

It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigating Consumer Report, Including information regarding my character, general reputation, personal characteristics, and mode of living. I agree to furnish such additional information and complete such examinations as may be required to complete my application file. 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. It is agreed and understood that this Application for Qualification in no way obligates the motor carrier to employ or hire the applicant. It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse. 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. I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted 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 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.

Choose ONE:*

I ACCEPTI DO NOT accept

Applicant Signature:

Date of Signature:*

Date of Signature.

EMPLOYMENT HISTORY

Driving Experience

Additional Information

Personal References:

To Be Read and Signed by Applicant: