12961 40th Avenue Chippewa Falls, WI. 54729 (715) 403-5599 Main number (715) 403-5598 Fax number APPLICATION FOR EMPLOYMENT Application Date Name of Driver Social Security Number Present Address City State Zip code How long? Date of Birth Position applied for Date available Phone number List all previous address(s) for the last 3 years preceding the date of application Dates Street Address City State Zip code Driver license information (include current and past licenses for the last 3 years) State License number Class/Endorsements Expiration date DRIVING EXPERIENCE List all experience in the operation of motor vehicles, including the type of equipment and time spent Type of equipment Period of time Nature and extent MOTOR VEHICLE ACCIDENTS List all motor vehicle accidents in which you were involved during the last 5 years preceding the date the application is submitted. Date Location Nature of Accident Fatalities/Injuries Preventability ruling
12961 40th Avenue Chippewa Falls, WI. 54729 (715) 403-5599 Main number Type of School Attended High school: EDUCATION School name and location Graduate? Diploma/Degree Grade point average Major course of study Technical/Vocational College/University Graduate school Professional Seminars or additional training EMPLOYMENT EXPERIENCE In order to process your application, please include the complete street address, including city, state and zip code, and phone number for all previous employers for the last 10 years; include all periods of unemployment.
(715) 403-5599 Main number
(715) 403-5599 Main number
12961 40th Avenue Chippewa Falls, WI. 54729 (715) 403-5599 Main number
(715) 403-5599 Main number COPY THIS PAGE IF NEEDED; MUST PROVIDE 10 YEARS OF CONTINUAL EMPLOYMENT HISTORY
(715) 403-5599 Main number TRAFFIC VIOLATIONS List all motor vehicle laws or ordinances or which you were convicted or forfeited bond or collateral during the last 3 years preceding of this application. Date Violation Location REVOCATIONS AND SUSPENSIONS Have you had a license, permit, or privilege to operate a motor vehicle denied, revoked, or suspended ever? YES NO Date Violation Explanation SPECIAL SKILLS AND QUALIFICATIONS Summarize special job-related skills and qualifications acquired from employment, schooling, and other experience not listed elsewhere on this application. I, the applicant certify that the application was completed by me, and that all entries on it and information contained in it are true and complete to the best of my knowledge. I understand that if I am employed, false statements may result in my immediate dismissal. I authorize the motor carrier to make an investigation of any of the facts set forth in this application. All offers of employment are conditional upon satisfactory reference checks, evidence, or completion of a DOT medical exam and receipt of a negative pre-employment drug screen. Applicant signature: Date: Employer signature: Date:
(715) 403-5599 Main number (715) 403-5598 Fax number EMPLOYEE AUTHORIZATION AND COMPANY REQUEST FOR INFORMATION FROM PREVIOUS EMPLOYER I hereby authorize you to provide the motor carrier with the following information regarding my past employment work history, alcohol and controlled substance testing results, services, character and conduct while in your employ. You are released from any and all liability that may result from furnishing such information. A photocopy of this authorization is to be considered valid as the original. Applicant signature Date Printed applicant name Social security number The above individual has applied with the motor carrier in a safety-sensitive position as a tractor/trailer CMV operator. In accordance with the FMCSR 391.23, 382.413 and 382.405, we are providing you will the driver s written authorization for the purpose of obtaining verification of the individual s safety performance history and drug & alcohol testing results. TO: Employment dates: FAX: Position(s): Power unit: Straight truck Tractor Bus (Motor coach/school) Other explain: Trailer equipment: Dry Van Reefer Tanker Dump Other explain: Experience: OTR Regional (states: ) Local Yard Accident(s): None Date: Preventable: Y / N Description: Date: Preventable: Y / N Description: Date: Preventable: Y / N Description: Still employed Quit (if quit, notice given?) Y / N Terminated Eligible for rehire: Yes No Upon review Performance and/or additional comments: Page 1 of 2
12961 40th Avenue Chippewa Falls, WI. 54729 (715) 403-5599 Main number Applicant Name: Circle one 1. Did the applicant test positive for a controlled substance in the previous three years Y / N 2. Did the applicant have an alcohol test with a BAC of 0.04 or greater in the previous three years Y / N 3. Did the applicant refuse a controlled substance or alcohol test in the last three years Y / N 4. Have you received information from a previous employer indicating that this individual violated Y / N 5. Has the applicant violated other DOT drug/alcohol regulations in the past three years Y / N 6. Was the applicant subjected to drug & alcohol testing under DOT regulations Y / N If you have answered YES to any of the above questions, please ATTACH documentation of the individual s successful completion of the results of the DOT Return-to-Duty and Follow-up tests and the Substance Abuse Professional s Name and contact information. SAP Name: City/State: Phone: Please include information received from other previous employers. Signature of person completed form Date Title Step 1. This form was faxed or mailed to the previous employer by: Circle one: 1 st attempt Sent by: Date: Faxed / Mailed / Email 2 nd attempt Sent by: Date: Faxed / Mailed / Email 3 rd attempt Sent by: Date: Faxed / Mailed / Email Step 2: This form was received from the previous employer and reviewed by: By: Date: Step 3: After good faith efforts to obtain the information required by FMCSRs, no responses were received from the above listed employer. By: Date: Page 2 of 2
(715) 403-5599 Main number (715) 403-5598 Fax number 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 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter I, of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol tests results, applicable school records, and your driving record may be obtained on you for employment purposes. These reports are required by sections 382.413, 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations. Driver Signature: Printed Name: Date: Social Security number: