The Powell Company CDL Driver s Application For Employment

Transcription

1 Signature of Applicant: The Powell Company CDL Driver s Application For Employment We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including age, race, color, national origin, gender, or religion. Name: Phone: ( ) First Middle Last *Current Address: Street City State Zip Code * If at the above residence less than three years, list below all residences for the past three years. Attach separate sheet if necessary. Date: Street City State Zip Code Street City State Zip Code Position applying for: Temporary Part Time Full Time Referred By: Rate of pay expected? Have you worked for this company before? Dates: From To Where? Rate of pay: Position: Names of any relatives employed by this company: Are you currently employed? If not, how long since leaving last employment? Education Circle highest grade completed: College: Last school attended: Name Address General Have you ever been bonded? (Answer only if a job requirement) Name of bonding company Have you ever been convicted of a felony? If yes, please explain fully on a separate sheet of paper. Conviction of a crime is not an automatic bar to employment - all circumstances will be considered. Have you ever worked for this company under another name? If so, under what name?

2 Driver Experience & Qualification Answer the questions in this section only if applying for driver position Date of Birth: month/day/year The U.S. Department of Transportation requires that driver applicants state their date of birth (391.21(b)(2)) Social Security No. - - Licenses Drivers Licenses held in past 3 years must be shown. State License No. Class Endorsement(s) Expiration Date A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? B. Has any license, permit or privilege ever been suspended or revoked? C. Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations? If you answered yes to A, B, C, attach a statement giving details. Yes Yes Yes No No No Driving Experience Class of Equipment Straight Truck Tractor and Semi-Trailer Twin Trailers - LCV s Other Type of Equipment Dates Approximate (Van, Tank, Flat, etc.) From To Total Miles List states operated in during last five years: List special courses or training that will help you as a driver: List driving awards held and who awards were presented by: Accident Review for past 3 years (Attach separate sheet of paper if more space is needed.) Dates Last Accident Next Previous Next Previous Nature of Accident (Head-On, Rear-End, Overturn, etc.) Fatalities Injuries Traffic Convictions and Forfeitures for the past 3 years other than parking violations Location Date Charge Penalty THIS PAGE MUST BE COMPLETED

3 Employment Record The U.S. Department of Transportation requires that driver applications show all employment for the past three years. They must also show commercial driver employment for the seven years immediately preceding this three year period (b)(10), (11) Start with last or current position, including military experience, and work back. (Attach a separate sheet of paper if necessary.) Current Employer: Supervisor s Full Name: Company: Supervisor s Full Name: Company: Supervisor s Full Name: Company: Supervisor s Full Name: Company: Supervisor s Full Name: Company: Supervisor s Full Name: Company: Supervisor s full name: Company: Supervisor s Full Name: Company: Supervisor s Full Name: THIS PAGE MUST BE COMPLETED

4 Platform Experience and Qualifications List types of platform experience and number of years of each: List platform equipment you can operate (lift truck, etc.): List courses or training in platform work: Applicant Must Read and Sign I certify that I have read and understood all of this employment application. It is agreed and understood that the employer or his agents may investigate my background to ascertain any and all information of concern to my employment history, whether same is of record or not, and I release employers and other persons named herin from all liability for any damages on account of furnishing such information. I understand that, as an applicant for a position with this company, 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 job, it may be conditioned on the results of a physical examination and drug test. I further certify that I am a genuine applicant for employment and this application is being submitted solely for the purpose of seeking employment with the employer and for no other reason. It is also agreed and understood that under the Fair Credit Reporting Act, Public Law , I have been told that 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 employment file. I also understand that misrepresentation or omission of information or facts may result in my rejection or dismissal. If hired, I agree to abide by all the rules and policies of the employer. 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. Date: Applicant Signature: For Office Use - Do Not Write In This Space Process Record Applicant Hired? Yes No Date of Birth: Date Employed: Point Employed: Department: Classification: (If not hired, summary report of reasons should be placed in file) IN CASE OF EMERGENCY NOTIFY: Phone: ( ) Address: This Section To Be Filled In By Responsible Officer Or Company Representative (month/day/year)* Superior Good Fair Below Average Poor Written Record on File 1. Application 2. Interview 3. Physical Exam* 4. Past Employment 5. Written Exam 6. Road Test 7. Policy and Traffic Record *driver applicants only Signature of Interviewing Officer: Date: From: Date: Reason for Transfer: To: Transfers From: Date: Reason for Transfer: Termination of Employment Date Terminated: Department Released From: Dismissed: Voluntarily Quit: Other: Termination Report Placed in File: Supervisor: To:

5 The Powell Company, Ltd. Need Copy of Drivers Licenses

6 Motor Vehicles Driver s CERTIFICATION OF COMPLIANCE WITH DRIVER LICENSE REQUIREMENTS MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 apply to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle weighing 26,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding. The requirements in Part 391 apply to every driver who operates in interstate commerce and operates a vehicle weighing 10,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding. DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain some requirements that you as a driver must comply with. These requirements are in effect as of July 1, They are as follows: 1) POSSESS ONLY ONE LICENSE: You, as a commercial vehicle driver, may not possess more than one motor vehicle operator s license. If you have more than one license, keep the license from your state of residence and return the additional licenses to the states that issued them. DESTROYING a license does not close the record in the state that issued it; you must notify the state. If a multiple license has been lost, stolen, or destroyed, close your record by notifying the state of issuance that you no longer want to be licensed by that state. 2) NOTIFICATION OF LICENSE SUSPENSION, REVOCATION OR CANCELLATION: Sections (b)(2) and of the Federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocation or suspension of your driver s license. In addition, Section requires that any time you violate a state or local traffic law (other than parking), you must report it within 30 days to: 1) your employing motor carrier, and 2) the state that issued your license (If the violation occurs in a state other than the one which issued your license). The notification to both the employer and state must be in writing. The following license is the only one I will possess: Driver's License No. State Exp. Date DRIVER CERTIFICATION: I certify that I have read and understood the above requirements. Driver's Name (Printed): Driver s Signature: Date Notes: (This form is not required for DOT compliance) 90-F 1617 Copyright 2000 J.J. KELLER & ASSOCIATES, INC., Neenah, WI USA (800) Printed in the United States (Rev. 10/00)

7 Company Name The Powell Company Fair Credit Reporting Act Disclosure Statement In accordance with the provisions of Section 604(b)(2)(A) of the Fair Credit Reporting Act, Public Law , as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter I, of Public Law ), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. These reports are required by Sections , , and of the Federal Motor Carrier Safety Regulations. Applicant s Signature Date Print Name Social Security Number

8 Motor Vehicle Driver s Certification of Violations/Annual Review of Driving Record MOTOR CARRIER INSTRUCTIONS: Each motor carrier shall at least once every 12 months, require each driver it employs to prepare and furnish it with a list of all violations of motor vehicle traffic laws and ordinances (other than violations involving only parking) of which the driver has been convicted, or on account of which he/she has forfeited bond or collateral during the preceding 12 months (Section ). Drivers who have provided information required by Section need not repeat that information on this form. DRIVER REQUIREMENTS: Each driver shall furnish the list as required by the motor carrier above. If the driver has not been convicted of or forfeited bond or collateral on account of any violation which must be listed, he/she shall so certify (Section ). COMPLETED BY DRIVER - CERTIFICATION OF VIOLATIONS NAME OF DRIVER (PRINT) SOCIAL SECURITY NUMBER DATE OF EMPLOYMENT HOME TERMINAL (CITY AND STATE) DRIVER S LICENSE NUMBER STATE EXPIRATION DATE I certify that the following is a true and complete list of traffic violations required to be listed (other than those I have provided under Part 383) for which I have been convicted or forfeited bond or collateral during the past 12 months. (If you have had no violations, check the following box None.) DATE OFFENSE LOCATION TYPE OF VEHICLE OPERATED If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation other than those I have provided under Part 383) required to be listed during the past 12 months. Date of Certification Driver s Signature COMPLETED BY MOTOR CARRIER - ANNUAL REVIEW OF DRIVING RECORD MOTOR CARRIER INSTRUCTIONS: Review the Certification of Violations listed above and other information described in Section of the Federal Motor Carrier Safety Regulations. Complete the information requested below. I have hereby reviewed the driving record of the above named driver in accordance with Section and find that he/she (check one): Meets minimum requirements for safe driving Does not adequately meet satisfactory safe driving performance Is disqualified to drive a motor vehicle pursuant to Section Action taken with driver: Reviewed by: Signature Date Printed Name Title Motor Carrier Name Motor Carrier Address MAINTAIN THIS DOCUMENT IN THE DRIVER S QUALIFICATION FILE. THIS DOCUMENT MAY BE PURGED AFTER 3 YEARS FROM DATE OF EXECUTION.

9 Authorization For Record Check Release of Criminal Records First Name Middle Name Last Name Maiden Name Address Apt. No. City State Zip Code Date of Birth Social Security No. I do hereby authorize any sheriff s department or police department to search their police records for any arrests, convictions or information they have regarding me and to make this information available to the personnel office of the company. I hereby waive any rights to privacy I may have under Federal or State Statute for the purpose of the release of this information. Date Signature Please list any addresses from the past 5 years Address City State Zip Code Address City State Zip Code Address City State Zip Code

10 DF - 6 DRIVER STATEMENT OF ON-DUTY HOURS (For Newly Hired Drivers) INSTRUCTION: Motor carriers when using a driver for the first time shall obtain from the driver a signed statement giving the total time on-duty during the immediately preceding 7 days and time at which such driver was last relieved from duty prior to beginning work for such carrier. Rule 395.8(j)(2) Federal Motor Carrier Safety Regulations. NOTE: Hours for any compensated work during the preceding 7 days, including work for a non-motor carrier entity, must be recorded on this form. Driver Name (Print) Social Security Number Driver s License: State Number Class Endorsement(s) Restriction(s) Type of License Issuing State DAY DATE 1 (yesterday) HOURS WORKED TOTAL HOURS I hereby certify that the information given above is correct to the best of my knowledge and belief, and that I was last relieved from work at A.M. P.M. On Time Day Month Year Driver s Signature Date DRIVER CERTIFICATION FOR OTHER COMPENSATED WORK INSTRUCTIONS: When employed by a motor carrier, a driver must report to the carrier all on-duty time including time working for other employers. The definition of on-duty time 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 nonmotor carrier entity. (check one) Are you currently working for another employer? Yes No At this time do you intend to work for another employer while still employed by Yes No this company? I hereby certify that the information given above is true and I understand that once I become employed with this company, if I begin working for any additional employer(s) for compensation that I must inform this company immediately of such employment activity. Driver s Signature Date Witness: Company Representative Date

11 Reimbursement Agreement for CDL Drivers The Powell Company, LTD. I understand that I am being considered for employment as a commercial truck driver, pending successful completion of certain Powell and Department of Transportation (DOT) requirements. Further, I understand that if I do not pass the Dot physical and/or the drug & alcohol test, or if I leave (quit or be terminated) employment within 90 days for any reason, the full cost of the DOT physical and the drug & alcohol test will be withheld from wages. Employee Signature Date THIS PAGE MUST BE SIGNED

12 Inquiry To Past Employers FROM - Prospective Employer TO - Previous Employer Company Individual Street Company Name Street City State Zip City State Zip Personnel Manager: The person named below has applied to this company for employment. Your firm is listed by the applicant as a past employer. Kindly reply to this inquiry respecting this applicant. As you will note from the waiver stated below, the applicant has waived any claim of liability against your company (and its agents) for information submitted in response to this inquiry. For your convenience in replying by return mail, we have enclosed a stamped, self-addressed envelope. Very Truly Yours, Name of applicant Social Security No. Job applied for 1. This applicant lists dates of employment with your firm from: to: Is this correct? Yes No If no, please explain: 2. What kind(s) of work did he/she do? Driver (type of vehicle ) Dock Office Shop Other (Specify) 3. If employed as a driver, please indicate type of equipment driven. Tractor Trailer Straight Truck Twin-Trailers Bus Other (Specify) 4. Number of recordable accidents number of accidents in which applicant was ticketed number of accidents in which the applicant was at fault (please explain) Date of each accident 5. To your knowledge, was this person s chauffeur/operator s license suspended while in your employ? If so, please explain 6. (Respond only if checked)* [ ] Was this person bonded while with your company? If so, were there any circumstances that were reported to the bonding company? *Prospective employer - check this question only if bonding is required for this position 7. Is there anything in the applicant s history that could suggest he or she may not be trusted to handle company funds? 8. Did the applicant pose either repeated and or severe disciplinary problems? Yes No If so, please explain 9. Why did this employee leave your company? Resigned Discharged Laid off 10. Would you re-employ this person? Yes No Please explain: 11. Remarks: By: (Signature of person supplying information) (Detach here for your files) Waiver Date: (Former Employer) (Date) I hereby authorize you to release all information concerning my employment including oral assessments of my job performance, ability, and fitness, to each and every company (or their authorized agents) which may request such information in connection with my application for employment with said company. I hereby release you from any and all liability of any type as a result of providing the above mentioned information to the above mentioned person. (Applicant s Signature) (Witness s Signature) THIS PAGE MUST BE SIGNED

13 Inquiry To Past Employers FROM - Prospective Employer TO - Previous Employer Company Individual Street Company Name Street City State Zip City State Zip Personnel Manager: The person named below has applied to this company for employment. Your firm is listed by the applicant as a past employer. Kindly reply to this inquiry respecting this applicant. As you will note from the waiver stated below, the applicant has waived any claim of liability against your company (and its agents) for information submitted in response to this inquiry. For your convenience in replying by return mail, we have enclosed a stamped, self-addressed envelope. Very Truly Yours, Name of applicant Social Security No. Job applied for 1. This applicant lists dates of employment with your firm from: to: Is this correct? Yes No If no, please explain: 2. What kind(s) of work did he/she do? Driver (type of vehicle ) Dock Office Shop Other (Specify) 3. If employed as a driver, please indicate type of equipment driven. Tractor Trailer Straight Truck Twin-Trailers Bus Other (Specify) 4. Number of recordable accidents number of accidents in which applicant was ticketed number of accidents in which the applicant was at fault (please explain) Date of each accident 5. To your knowledge, was this person s chauffeur/operator s license suspended while in your employ? If so, please explain 6. (Respond only if checked)* [ ] Was this person bonded while with your company? If so, were there any circumstances that were reported to the bonding company? *Prospective employer - check this question only if bonding is required for this position 7. Is there anything in the applicant s history that could suggest he or she may not be trusted to handle company funds? 8. Did the applicant pose either repeated and or severe disciplinary problems? Yes No If so, please explain 9. Why did this employee leave your company? Resigned Discharged Laid off 10. Would you re-employ this person? Yes No Please explain: 11. Remarks: By: (Signature of person supplying information) (Detach here for your files) Waiver Date: (Former Employer) (Date) I hereby authorize you to release all information concerning my employment including oral assessments of my job performance, ability, and fitness, to each and every company (or their authorized agents) which may request such information in connection with my application for employment with said company. I hereby release you from any and all liability of any type as a result of providing the above mentioned information to the above mentioned person. (Applicant s Signature) (Witness s Signature) THIS PAGE MUST BE SIGNED

14 Inquiry To Past Employers FROM - Prospective Employer TO - Previous Employer Company Individual Street Company Name Street City State Zip City State Zip Personnel Manager: The person named below has applied to this company for employment. Your firm is listed by the applicant as a past employer. Kindly reply to this inquiry respecting this applicant. As you will note from the waiver stated below, the applicant has waived any claim of liability against your company (and its agents) for information submitted in response to this inquiry. For your convenience in replying by return mail, we have enclosed a stamped, self-addressed envelope. Very Truly Yours, Name of applicant Social Security No. Job applied for 1. This applicant lists dates of employment with your firm from: to: Is this correct? Yes No If no, please explain: 2. What kind(s) of work did he/she do? Driver (type of vehicle ) Dock Office Shop Other (Specify) 3. If employed as a driver, please indicate type of equipment driven. Tractor Trailer Straight Truck Twin-Trailers Bus Other (Specify) 4. Number of recordable accidents number of accidents in which applicant was ticketed number of accidents in which the applicant was at fault (please explain) Date of each accident 5. To your knowledge, was this person s chauffeur/operator s license suspended while in your employ? If so, please explain 6. (Respond only if checked)* [ ] Was this person bonded while with your company? If so, were there any circumstances that were reported to the bonding company? *Prospective employer - check this question only if bonding is required for this position 7. Is there anything in the applicant s history that could suggest he or she may not be trusted to handle company funds? 8. Did the applicant pose either repeated and or severe disciplinary problems? Yes No If so, please explain 9. Why did this employee leave your company? Resigned Discharged Laid off 10. Would you re-employ this person? Yes No Please explain: 11. Remarks: By: (Signature of person supplying information) (Detach here for your files) Waiver Date: (Former Employer) (Date) I hereby authorize you to release all information concerning my employment including oral assessments of my job performance, ability, and fitness, to each and every company (or their authorized agents) which may request such information in connection with my application for employment with said company. I hereby release you from any and all liability of any type as a result of providing the above mentioned information to the above mentioned person. (Applicant s Signature) (Witness s Signature) THIS PAGE MUST BE SIGNED

15 Name of Job Applicant/Employee Applicant Date of Birth Applicant Social Security # Applicant Driver License# Address: City, State, Zip Code Date Powell Company 750 Buckeye Rd Lima, OH Dear Powell Company Consumer reports may be obtained as part of the Powell Company evaluation of my job application /employment. The reports may be procured by Webb Insurance Agency, Inc., and may include my driving record, an assessment of my insurability under the Company s insurance coverage and other consumer reports. By signing this disclosure, I hereby authorize the Company to procure such reports and additional reports about me from time to time, as it deems appropriate, to evaluate my insurability or for other permissible purposes. Sincerely, Signature of Applicant or Employee Typed or Printed Name of Applicant or Employee

16 Office of Housing and Community Partnerships Ohio Small Cities Community Development Block Grant Program Job Benefit Verification Employee Certification Your current/perspective employer, which appears below, is the recipient of financial assistance through the federally funded Ohio Community Development Block Grant (CDBG) Small Cities Program. As a result of the assistance received, the business must provide data on job creation and/or retention. This information is not part of the interview process and will not be considered for hiring purposes. This information is, however, subject to verification by authorized government officials. The Powell Company, Ltd. A. Name of Employer: (print) 3255 St. Johns Road, Lima, Ohio Address of Employer: (print) Name of Employee: (print) B. Race, Ethnicity, Gender and Disability Status. Please mark only one of the following race classifications: White Multi-Racial: Black/African American Black/African American & White American Indian/Alaska Native American Indian/Alaska Native & White Asian Asian & White Native Hawaiian/Other Pacific Islander American Indian/Alaska Native & Black/African American Other Multi-Racial Please check Yes or No : Hispanic or Latino: Yes: No: Please check all that apply: Male: Female: Female Head of Household: Disabled: Unemployed: C. Circle your household size & one income range in the corresponding row that represents your household income for the prior 12 months: Household Size Income Range (30%) Income Range (50%) Income Range (80%) Income Range (NL) 1 person 2 person 3 person 4 person 5 person 6 person 7 person 8 persons or more 0 - $11, $13, $15, $17, $18, $19, $21, $22,500 $11,951 - $19,900 $13,651 - $22,750 $15,351 - $25,600 $17,051- $28,450 $18,401 - $30,750 $19,801 - $33,000 $21,151 - $35,300 $22,501 - $37,550 $19,901 - $31,850 $22,751 - $36,400 $25,601 - $40,950 $28,451- $45,500 $30,751 - $49,150 $33,001 - $52,800 $35,301 - $56,400 $37,551 - $60,050 Above $31,850 Above $36,400 Above $40,950 Above $45,500 Above $49,150 Above $52,800 Above $56,400 Above $60,050 D. Employee Signature: Date: / / =================== Do Not Write Below This Line To Be Completed By Employer After Hire ===================== Job Description (check one): Manager/Professional: Sales: Office/Clerical: Service: Technician: Other: Date Employed (mo./day/yr.): / / Check one: Full-Time: Part-Time (less than 35 hrs/wk): =================== Do Not Write Below This Line To Be Completed By Grant Adminstrator ====================== Allen County: FY: LMI Qualified Y: N: THIS PAGE MUST BE SIGNED