RES America Construction, Inc. 9050 N Capital of TX Hwy, Ste 390, Austin, TX 78759 DOT APPLICATION FOR EMPLOYMENT In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status Positions(s) Applied For: Cell # Name: Last Suffix First Middle Date of Birth: Social Security #: Current Address: Past Three Years: Address: Address: Address: Referred by? Expected pay rate: Have you worked for this company before? Yes If yes, where? Date Employed: Pay rate: Position: Reason for leaving: Are you employed now? Yes Have you ever been fired or asked to resign by an employer? Yes Do you have a legal right to work in the United States? Yes Have you ever been convicted of a felony? Yes Have you ever failed a D.O.T Drug and/or Alcohol Test? Yes Have you ever refused to take a D.O.T Drug and/or Alcohol Test? Yes Have you ever violated any D.O.T. Drug and/or alcohol Regulation? Yes Have you ever been bonded? Yes If yes, Bonding : Is there any reason you might not be able to perform the functions of the job for which you have applied (as described in the attached job description)? Yes If yes, explain: RES America Construction, Inc. Page 1 DOT Employment Application
License Information State License # Class Endorsements Restrictions Expirations Date Driving Experience Equipment Yes/ Approximate Miles (Total) Straight Truck Tractor & Semi-Trailer HM-Fuel & Lube Truck Water Truck Bucket Truck Manual / Standard Transmission Other Dates Nature of Accident Accident Record for the past 3 years # of Fatalities # of Injuries Chemical Spills Y/N Date Convicted Traffic Convictions and Forfeitures for the past 3 years (other than parking violations) Violation State of Violation Penalty A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle? Yes B. Has any license, permit, or privilege been suspended or revoked? Yes If yes to either A or B, explain: RES America Construction, Inc. Page 2 DOT Employment Application
High School College Trade/Vocational Education Name Location (City,State) Degree/Diploma Date EMPLOYMENT HISTORY All applicants eligible to drive a commercial motor vehicle must provide the following information on past and present employers during the last 3 years. List complete mailing address, street number, city, state and zip code. Applicants to drive a commercial motor vehicle* requiring a commercial driver s license (CDL) shall also provide an additional 7 years' of employment history. (NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary. If unemployed for a certain time period, state unemployed for that period. There should be NO GAPs in employment history) Current or most Recent Employer RES America Construction, Inc. Page 3 DOT Employment Application
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TO BE READ AND SIGNED BY APPLICANT I authorize you to make sure investigations and inquiries to my personal, employment or medical information and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if related to a DOT medical certification) 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. 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. 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 391.23(d) and (e). I understand that I have the right to: Review information provided by current/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. DATE APPLICANT'S SIGNATURE This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. DATE APPLICANT'S SIGNATURE te: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations. RES America Construction, Inc. Page 6 DOT Employment Application