STONY RUN ENTERPRISES

Transcription

1 STONY RUN ENTERPRISES Please follow these instructions for filling out the application. 1. Please save a blank copy of the form to your computer before filling it out. 2. Fill out the full application, then save the filled out application to your computer. 3. Print the filled out application. 4. Please sign were indicated with a handwritten signature. No application will be processed without a signature. 5. Provide any additional documentation required. 6. U.S. Mail, fax or drop the full application off to our offices: Stony Run Enterprises 3772 Old Oxford Road Hamilton, Ohio Phone: Fax:

2 STONY RUN ENTERPRISES APPLICATION (Please fill out all pages, save the file to your computer for your copy, than print a copy to provide to Stony Run Enterprises. You can either U.S. mail, fax or drop the full application off to our offices.) 3772 Old Oxford Road, Hamilton, OH Phone Fax In compliance with Federal and State equal opportunity laws, qualified applicants are considered for all positions without regard to race, religion, sex, national origin, age, marital status, or non-job related disability. TO BE READ AND SIGNED BY APPLICANT 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 (d) and (e). I also understand that I have the right to: A. Review information provided by previous employers B. Have errors in the information corrected by previous employers and for those precious employers to re-send the corrected information to the prospective employer, and C. 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 Signature: Date: Name: Social Security #: Address: How long have you lived there? Phone #: Have you provided services to this company before? If yes what year? Position Reason for leaving? Are you working now? If not, how long since your last job? Who referred you? Do you know anyone in our service? Previous Addresses for the Past Three (3) Years: Address: City: State: Zip: From: To: Address: City: State: Zip: From: To: Address: City: State: Zip: From: To:

3 Business activity for the past ten years (as required by law) (Attach sheet if more space if needed. We must have full and current address for all employers) Name: Phone #: Address: Fax#: City: State: Zip Code: Position: From: To: Compensation: Reason for leaving: Name: Phone #: Address: Fax#: City: State: Zip Code: Position: From: To: Compensation: Reason for leaving: Name: Phone #: Address: Fax#: City: State: Zip Code: Position: From: To: Compensation: Reason for leaving: Name: Phone #: Address: Fax#: City: State: Zip Code: Position: From: To: Compensation: Reason for leaving:

4 Business activity for the past ten years (as required by law) (Attach sheet if more space if needed. We must have full and current address for all employers) Name: Phone #: Address: Fax#: City: State: Zip Code: Position: From: To: Compensation: Reason for leaving: Name: Phone #: Address: Fax#: City: State: Zip Code: Position: From: To: Compensation: Reason for leaving: Name: Phone #: Address: Fax#: City: State: Zip Code: Position: From: To: Compensation: Reason for leaving: Name: Phone #: Address: Fax#: City: State: Zip Code: Position: From: To: Compensation: Reason for leaving:

5 Experience and Qualification-Driver License Number: State of license held: Endorsements: Expiration date: Have you ever been denied a license, permit or privilege to operate a motor vehicle: Yes No Has any license, permit or privilege ever been suspended or revoked: Yes No If you answer yes to question 1 or 2 please attach a statement giving details. Driving Experience Straight Truck Dates: Miles: Tractor & Semi Trailer Dates: Miles: Other Dates: Miles: List states operated in for last five years: List special courses or training that you have had as a driver: What safe driving awards do you hold and from whom: Accident record for past three years or more (We must have a copy of each accident report.) Accident Date: State that accident happened in: Nature of accident: Fatalities: Injury: Accident Date: State that accident happened in: Nature of accident: Fatalities: Injury: Accident Date: State that accident happened in: Nature of accident: Fatalities: Injury:

6 Experience and Qualification- Equipment and Products Type of non-bulk equipment used: (check which apply) Van Low Boy Grain Flat Livestock Dump Type of bulk equipment used: (check which apply) Dry Liquid LPG Type of products handled: (check which apply) Hazardous Non-hazardous Agricultural products Explosives ( Class 1) Gases ( Class 2) Flammable and Combustible liquid (Class 3) Flammable solid, spontaneously combustible material dangerous When wet material (Class 4) Oxidizers and organic peroxides (Class 5) Poisonous material and infectious substance (Class 6) Radioactive material (Class 7) Corrosive material ( Class 8) Miscellaneous hazardous material ( Class 9) Other Equipment Used PTO pump PTO blower PTO air Customer Air Vacuum Portable Vacuum Meter Other product hauling and handling experience: Traffic Convictions and Forfeitures for the Past Three Years Location: Date: Charge: Penalty: Location: Date: Charge: Penalty: Location: Date: Charge: Penalty:

7 Experience and Qualifications-Other List any trucking, transportation or other experience that may help in your service for this company: List course and training other than shown elsewhere on this form: List Special Equipment or technical materials you can work with (other than those already shown): Military Status Have you served in the U.S. Armed Forces: Yes No Branch: From: To: Rank at discharge: Date of discharge: Specialized Training: Education Check highest grade completed: High School: College: Other: Last school attended: Are you a U.S. Citizen: Yes No Personal Background Have you ever been convicted of a felony: Yes No If yes, Date, Explain: Have you ever been convicted of a misdemeanor involving theft or violence? Yes No If yes, Date, Explain: Are there any current proceedings pending which once resolved, may affect either of your responses above? Yes No If yes, Date, Explain: Are there any other names you have used in the past of which we should be aware in order to verify any information provided: Yes No If yes, please list:

8 To be Read and Sign by Driver and or Contractor/Operator This certifies that this application was completed by me, and that all entries on it and information it is true and complete to the best of my knowledge. I understand that the accuracy and completeness of the information provided in this application, and supplemental forms, or pre-employment interviews is relied upon by Stony Run Enterprises, Inc. in making an employment decision. I understand that it is my responsibility to notify Stony Run Enterprises, Inc. of any change in the information provided during the employment process. I understand that any misrepresentation, misstatement, omission or other attempt to mislead, at any stage of the employment process, is grounds for refusal to hire or, if already hired at the time of discovery, my dismissal. I understand that, if I am selected for possible employment, a criminal background check may be conducted to verify the information I have provided. I also understand that any prior employer or reference may be contacted either before or after a conditional offer is extended. I hereby authorize and request any former employer, or any other persons or companies, including any city, county, state or federal agency, department or bureau, to furnish to Stony Run Enterprises, Inc. or its authorized representatives, any information in their files under my name. I agree to hold any source of information harmless for any error in reporting this information and release all such persons from any damages on account of furnishing said information. A photocopy of this authorization may be accepted by anyone as though it were the original. I agree and understand that Stony Run Enterprises, Inc. or its agents may investigate my background to ascertain any and all information of concern to my previous business activity. Whether is of record or not. I hereby release Employers, schools, health care providers and other persons from all liability for any damages in responding to such request for information. I understand that in seeking a driver or contractor/ Operator position with Stony Run Enterprises, Inc. I may be asked to demonstrate that I am capable of performing tasks which are pertinent to the job. I also understand that if offered a driver or contractor\operator position with the company, it may be conditioned on results of a DOT physical examination and drug test. I also agree and understand that under the Fair Credit Reporting Act, Public law , I have been told this investigation may include an Investigative 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 Driver or Contractor/ Operator file. If employed, I agree to conform to the rules and regulations of the company and acknowledge that their rules and regulations may be changed, interpreted, withdrawn, or added to by the company at any time, at the company s sole option and without any prior notice to me. I agree to abide by the rules and regulations of the carrier as well as the Federal Motor Carrier Safety Regulation. I further acknowledge that my employment may be terminated, and any offer of employment, or my acceptance of an employment offer, if such is to occur, may be withdrawn at any time, with or without cause, at the option of the company or myself. I understand that all employment is at will and that no representative of the company has authority to enter into any agreement for employment for any specified period of time or to assure any other personnel action, either prior to commencement of employment or after I have become employed, or to assure any benefits or terms and conditions of employment, or make any agreement contrary to the foregoing. I acknowledge that I have been advised that this application will remain active for no more than 90 days from the date it was make. It is agreed and understood that this application for qualification in no way obligates the motor carrier to employ me. I understand I have a 90 day probation period. Prospective employees will receive consideration without discrimination base on race, creed, color, sex, age, national origin, handicap, veteran status or any condition prescribed by state, federal or local law. I certify I completed this Driver or Contractor / Operator information and history, and all entries and information are true and complete to the best of my knowledge. Name: Social Security #: Signature: Date: D.O.B.:

9 3772 Old Oxford Road, Hamilton, OH Phone (Please Fax Back to ) Request For Information From Previous Employer Date: Dear Sir/Madam: has applied to Stony Run Enterprises, Inc. for a position as and states he/she worked for you as a from to. We appreciate you time in completing, in confidence, the information on the reverse side. Please circle appropriate response or complete information. A self-address stamped envelope is enclosed for you convenience. We would refer this returned by fax. Thank you for your courtesy. Sincerely, Please take a moment and complete the information requested in Page 2. We would appreciate your prompt response. As you are aware, after October 29, 2004, failures to respond within 30 days to investigative request for safety performance history will result in a complaint notification being filed with the Federal Motor Carrier Administration using the complaint process specified at This form is being (check one): Faxed Mailed ed Other Completed by Phone with I hereby authorize the release of the following information to Stony Run Enterprises, Inc. for the purpose of investigation as required by Sections , , and of the Federal Motor Carrier Safety Regulations. You are released from any and all liability which may result from furnishing such information. Applicant Signature: Date: Page 1 of 2

10 3772 Old Oxford Road, Hamilton, OH Phone (Please Fax Back to ) Applicant Name: Social Security #: Did the above named applicant work for you company: Yes No If Yes. Please state actual dates of Employment to What motor vehicle did he/she drive for you: Straight Truck Tractor-Semi Trailer Bus Other Was he/she a safe, efficient, & courteous driver: Yes No Reason for leaving: Did he/she give you a notice: Yes No How long of a notice. Was his/her conduct satisfactory? Yes No Is he/she eligible for re-hire? Yes No Accident History: Please give the following information for any accidents included on your accident register (390.15(b)) that involved the applicant (regardless of fault) which occurred while in your employment. Or check here if there is 0 accident register data for this applicant. Date City, State Description # of injuries # of Fatalities HazMat Spill Yes No Yes No Yes No Yes No Drug and Alcohol History If the applicant was not subject to Part 382 testing requirements while employed by you, please check here sign below and return. If subject to Part 382 testing requirements: Yes No Has this person ever tested positive for a controlled substance: Yes No Has this person ever had an alcohol test with a Breath Alcohol Concentration 0.04 or more: Yes No Has this person ever refused a required test for drugs or alcohol: Yes No Has this individual violated other DOT drug/alcohol regulations: Yes No Have you received information from a previous employer that this individual violated: Yes No DOT drug and alcohol regulation: Yes No If yes to any of the above questions, please give the SAP s (Substance Abuse Professional) name, address and telephone number for further reference. Name: Address: City, State, Zip: Additional information or comments: Signature: Title: Date: Page 2 of 2

11 DISCLOSURE AND RELEASE In connection with my application for employment (including contract for services) with you. I understand that consumer reports which may contain public record information may be requested from DAC Services, Tulsa, OK. These reports may include the following types of experience, accidents, etc. I further understand that such reports may contain public record information concerning my driving record, worker s compensation claims, credit, bankruptcy proceedings, criminal records, etc. from federal, state, and other agencies which maintain such records; as well as information from DAC concerning previous driving record requests made by others from such state agencies, and state provided driving records. I authorize, without reservation, any party or agency contacted by DAC to furnish the abovementioned information. I have the right to make a request to DAC, upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including the sources of information; and the recipients of any reports on me which DAC has preciously furnished within two year period preceding my request. I hereby consent to your obtaining the above information from DAC, and I agree that such information which DAC has or obtains, and my employment history with you if I am hired, will be supplied by DAC to other companies which subscribe to DAC services. I hereby authorize procurement of consumer report(s). If hired (or contracted), this authorization shall remain on file and shall serve as ongoing authorization for you to procure consumer reports at any time during my employment (or contract) period. Print Name Social Security # Applicant s Signature Date

12 Personal Information Sheet Name: Address: State and Zip: Telephone No: Mobil No: Pager No: Date of Birth: Social Security #: Federal ID #: Driver License: State & Expiration: In case of emergency, people to notify: FIRST CONTACT: Name: Home #: Address: Work #: City, State, Zip: Pager #: Relationship: Mobil #: SECOND CONTACT: Name: Home #: Address: Work #: City, State, Zip: Pager #: Relationship: Mobil #: THIRD CONTACT: Name: Home #: Address: Work #: City, State, Zip: Pager #: Relationship: Mobil #: Please complete the change of information form when any the above information changes.

13 Driver Data Sheet For Intermittent, Causal, or Occasional Operators The Federal Motor Carrier Safety regulations require motor carriers, when using a driver for the first time or intermittently, to obtain from the driver a signed statement giving the total time on duty and during the immediately preceding seven (7) days, and the time at which the driver was last relieved from duty prior to beginning work for us. My total time on duty during the immediately preceding seven (7) days is: Day Date Hours Total Hours I was last relieved from duty at (time) on (date). Name: (Print) Social Security Number: Issuing State: Driver License Class Endorsements Restrictions I hereby certify that the information given above is correct to the best of my knowledge and belief. When employed by a motor carrier, a driver must report to the motor carrier all on-duty time working or other employers. The definition of on-duty found in Section paragraphs 8 and 9 of the Federal Motor Carrier Safety Regulations includes time performing any other work in the capacity of, or in the employ or service of a common, contract or private motor carrier, also performing any compensated work for any non-motor carrier entity. Are you currently working for another employer: Yes No At this time do you intend to work for another employer still employed by this company: Yes No I hereby certify that the information given above is true. I understand that once I begin driving for this company, if I begin working for any additional employer(s) for compensation that I must inform this company immediately of such employment activity. Signature: Date: Company Representative: Date:

14 Notice to Prospective New Employees You have been offered a position with Stony Run Enterprises, Inc. Your position, however, is contingent upon passing a medical examination, including drug testing, with our company physicians. By paying for your physical examination and drug testing, Stony Run Enterprises, Inc. is investing money in your future with the company. The cost of the medical examination and drug testing is high. We therefore require you to be certain that you want to work for Stony Run Enterprises, Inc. prior to undergoing the medical examination and drug testing. As a condition of your employment, Stony Run Enterprises, Inc. requires you to reimburse us for the cost of the medical examination, drug testing and any training pay, in the event that you become separated from employment with us on or before (180) one hundred eighty days from your first day on the job. Separated from employment means: (1) you resign your position; (2) you abandon your position (3) consecutive work days No-Call/No Show); or, (3) you are discharged for cause. In the event you become separated from employment on or before the one hundred eighty day following your first day on the job, then you agree to permit us to deduct the cost of the medical examination and drug testing from you final paycheck. We will provide you with a copy of our clinic s bills. Should you owe the company money as in pay advances, or emergency advance money, This amount will be deducted from any future pay checks until it is repaid in full. Any amount unpaid, you will be sent a tax form Misc 1099 for money your received that were not wages. You will be responsible for payment of any federal, state, and social security taxes. On this day of, 20. I Agree to the terms of this notice. (Print Name) Stony Run Enterprises, Inc. Representative (Signature)

15 DISCLOSURE AND RELEASE In connection with my application for employment (including contract for services) with you. I understand that consumer reports which may contain public record information may be requested from DAC Services, Tulsa, OK. These reports may include the following types of experience, accidents, etc. I further understand that such reports may contain public record information concerning my driving record, worker s compensation claims, credit, bankruptcy proceedings, criminal records, etc. from federal, state, and other agencies which maintain such records; as well as information from DAC concerning previous driving record requests made by others from such state agencies, and state provided driving records. I hereby authorize the Stony Run Enterprises, Inc. representative release of records from Worker s Compensation listed below. I understand the record may include date of injury, type of injury, and time loss of work. If hired (or contracted), this authorization shall remain on file and shall serve as ongoing authorization for you to procure consumer reports at any time during my employment (or contract) period. On this day of, 20. I Agree to the terms of this notice. (Print Name) Stony Run Enterprises, Inc. Representative (Signature)

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19 STONY RUN ENTERPRISES 3772 Old Oxford Road, Hamilton, OH Phone Fax DRIVER APPLICATION CHECKLIST APPLICANT: DATE RECEIVED: PHONE NO: Application for employment Motor Vehicle Report (MVR) Record of Road Test/Certification of Road Test Request for Information from Previous Employer Employment Eligibility Verification (I-9) Personal Information File Form Copy of Commercial Drivers License (front & back) Internal Revenue Service W-4 (Company employee) W-9 (Contractor/Operator) Physical Examination Controlled Substance Screening and Result Driver Data Sheet (completed when ready to start work) Copy of Social Security Card Copy of Birth Certificate Ohio New Hire BWC C-110 CHECK Reviewed by: Approved by: Date: Hired Not Hired (Please fill out all pages, save the file to your computer for your copy, than print a copy to provide to Stony Run Enterprises. You can either U.S. mail, fax or drop the full application off to our offices.) 3772 Old Oxford Road, Hamilton, OH Phone Fax