Return To: URT/Texas, Inc. - WHW Towing Companies, PO Box 59327, Dallas TX 75229 - Fax To: 972.484.6496 - Email To: dallassafety@unitedroadtowing.com APPLICATION FOR EMPLOYMENT Name: FIRST-MIDDLE-LAST (AS IT APPEARS ON SOCIAL SECURITY CARD) SOCIAL SECURITY NO. TODAY'S DATE FORMER NAME HOME (AREA CODE) CELL (AREA CODE) E-mail CALIFORNIA APPLICANTS: DO NOT COMPLETE SOCIAL SECURITY NUMBER UNLESS HIRED List below all address at which you have lived in the last five (5) years Start with your present address DATE STREET CITY STATE ZIP CODE FROM TO PRESENT PREVIOUS PREVIOUS PREVIOUS PREVIOUS DO NOT SHOW FOREIGN RESIDENCE IF IT MAY INDICATE NATIONAL ORIGIN, UNLESS HIRED. SELECT THE JOB YOUR ARE APPLYING FOR - PLEASE CHECK ONLY ONE FROM THIS LIST. Yard worker Management Trainee Manager At Headquarters Tow truck driver Customer Service/ Clerical Professional Line Haul / Sleeper Driver Intern Technical Mechanic / welder Sales Position Clerical Dispatcher Accounting Accounting Combination Driver/Yard Worker Other Other WHAT RATE OF PAY DO YOU EXPECT IF HIRED WHEN COULD YOU BEGIN TO WORK DESCRIBE THE TYPE OF WORK YOU WANT FULL TIME ON CALL PART TIME ANY OF THESE AVAILABILITY ARE YOU ABLE TO WORK ANY DAY OF THE WEEK AND ANY SHIFT DURING THE DAY YES NO IF NO, WHAT DAY(S) OF THE WEEK OR SHIFT(S) DURING THE DAY CAN YOU WORK? EDUCATION CIRCLE HIGHEST LEVEL ACHIEVED GRUDUATED /GED MAJOR DEGREE RECEIVED YES / NO ELEMENTARY 1 2 3 4 5 6 JR/SR HIGH SCHOOL 7 8 9 10 11 12 TECHNICAL SCHOOL (NAME) 1 2 3 COLLEGE (NAME) 1 2 3 4 COLLEGE (NAME) 1 2 3 4 OTHER (NAME) 1 2 3 4 NEW JERSEY APPLICANTS DO NOT COMPLETE GRADUATED/GED COLUMN UNLESS HIRED. HAVE YOU PREVIOUSLY APPLIED AT OR BEEN APPLIED INDICATE NAME USED WHEN APPLYING OR EMPLOYED ARE YOU AT LEAST IF NO EMPLOYED BY UNITED ROAD TOWING UNDER EMPLOYED 18 YEARS YES STATE YOUR PRESENT OR ANY OTHER NAME NEITHER OF AGE NO YOUR AGE: DATE IF PREVIOUSLY EMPLOYED BY A UNITED ROAD SERICE COMPANY COMPLETE THIS SECITON POSITION HELD OR APPLIED FOR LOCATION APPLIED DATE HIRED DATE LEFT REASON FOR LEAVING DO YOU KNOW ANYONE EMPLOYEED UNITED ROAD SERVCIE YES NO WHO? FIRST AND LAST NAMES POSITION LOCATION RELATIONSHIP ARE YOU RELATED BY BLOOD OR MARRIAGE TO ANYONE EMPLOYED BY UNITED ROAD TOWING YES NO PROVIDE THE NAME OF THE INDIVIDUAL OR ORGANIZATION THAT REFERRED YOU
EMPLOYMENT, EDUCATION, AND MILITARY RECORD, ETC.: LIST PRESENT AND ALL PREVIOUS EMPLOYMENT, MILITARY SERVICE AND EDUCATIONAL EXPERIENCE DURING THE PAST TEN (10) YEARS. INCLUDE ALL PERIODS OF UNEMPLOYMENT LASTING SIX MONTHS OR MORE. ARE YOU CURRENTLY EMPLOYED? YES NO PRESENT EMPLOYER MONTH/YEAR HIRED: May we contact your current employer YES NO REASON FOR APPLYING WITH UNITED ROAD TOWING: RATE OF PAY: FORMER EMPLOYER MONTH/YEAR HIRED: Month/year separated: FORMER EMPLOYER MONTH/YEAR HIRED: Month/year separated: FORMER EMPLOYER MONTH/YEAR HIRED: Month/year separated: FORMER EMPLOYER MONTH/YEAR HIRED: Month/year separated:
FORMER EMPLOYER MONTH/YEAR HIRED: Month year separated: FORMER EMPLOYER MONTH/YEAR HIRED: Month year separated: FORMER EMPLOYER MONTH/YEAR HIRED: Month year separated: FORMER EMPLOYER MONTH/YEAR HIRED: Month year separated: Provide dates and explain any period of six months or more when you were not in school and not working within the past ten years:
Have you ever served in the U.S. Military or Armed Forces? Yes No If yes, what branch Your primary specialty: Rank at discharge: Type of Discharge California and Ohio applicants do not complete type of discharge information unless hired. Have you ever been convicted of a crime involving alcohol or other controlled substance, arson, explosives, firearms, or other weapons, theft, dishonesty, threats, or violence under your current or any other name? Yes If yes describe below No Note: A conviction will not necessarily prevent you from being offered employment. Offense: Date Convicted: Penalty Disposition Occurred in the workplace: Yes No Name under which you were convicted Offense: Date Convicted: Penalty Disposition Occurred in the workplace: Yes No Name under which you were convicted Yard Workers Only Do you have a commercial Yes Operators License Number State Expiration Date Drivers License (CDL)? No Indicate years of Lift Truck - electric Lift Truck - gas Freight Handler OTHER Checker OTHER experience in each category shown. Indicate any other related work experience: Garage Applicants Only Have you had Yes No of Years Have you had Yes Years Gas Years Diesel Show Your Area(s) of Auto Shop No Truck Stop No Specialization Below: Experience Experience Training Experience Training Experience Training Experience Equipment X YRS. X YRS Equipment X Yrs X Yrs Equipment X Yrs X Yrs Wood Working Body Work Oxyacetylene Welder Sheet Metal Elec & Ignition Paint Spray Gun Clutch Rebuilding Engine Rebuilding Air Brakes Differential Rebuilding Diesel Injection Other: Transmission Rebuilding Electric Welder Other: Clerical and Administrative Place a check next to all the skills or types of work in which you have had training or experience indicate the number of years training/experience for each skill/type of work. Training Experience Training Experience Training Experience Skill X YRS. X YRS Skill X Yrs X Yrs Skill X Yrs X Yrs Typing WPM Dispatch Cashier Shorthand WPM Switch Board Computer Word Processing Accounts Payable Computer Spread Sheet Accounts Receivable LIST THE COMPUTER PROGRAMS AND EQUIPMENT WITH WHICH YOU ARE FAMILIAR:
DRIVER APPLICATION ONLY Date of Birth State number of years driving List States List unexpired personal and Commercial Drivers Licenses or Permits experience in each category You have Date Issued Type driven in License Number State Issued Expires Type of Years Experience Other regularly Vehicle Gas Diesel Straight Truck Tow Truck Roll-back Light duty Medium Duty Heavy Duty Tractor Trailer Double Single Triple Car Carrier 5th Wheel Stinger Steer List All Current Endorsements: Indicate any awards you have received for safe driving and from whom: Have you Ever had either your personal or Commercial Driver's License, permit or privileges denied, revoked or suspended? Denied Revoked Suspended Type of License Date State For How Long Reason Have you been convicted or forfeited bond or collateral for violation of Motor Vehicle Laws or Ordinances Yes If Yes, complete below. (other than parking) During the past four (4) years prior to the date of this application. No Date Nature of Violation State Penalty Points Have you ever had any Commercial Yes List below all accidents you have had while operating any type Motor Vehicle Accidents No of motor vehicle during the past five (5) years: Where Type on off prevent non- Date Nature of Accident No. of Deaths No. of Injuries Vehicle Type road road abe prevent Have you ever refused to be tested or tested positive on an alcohol or controlled substances test based on DOT Federal Motor Carrier Safety Regulations in the past 3 years? Yes No If yes, can you provide Documentation from the substance abuse professional certifying that you have successful completed the prescribed treatment and have been recommended to a DOT regulated safety sensitive position as specified in the Federal Motor Carrier Safety Regulations? Yes No Date of Last IF KNOWN PLEASE PROVIDE DOT Physical Doctor's Name Did you qualify? Yes No Any Restrictions? Yes No Doctor's Address Doctor's Phone Pursuant to the Provisions of paragraph (b) (10) of Section 391.21 of the Federal Motor Carrier Safety Regulations you are hereby Notified that if you are to be considered for employment by United Road Towing, Inc. The information which you have provided in Accordance with this paragraph may be used, and your prior employers may be contacted for the purpose of investigating your background as required by Section 391.23. Driver Applicant Signature Date
This Application will remain active for a period of three (3) months from the date of application. All applicants must read and sign below: It is agreed and understood that: 1 Completing this application will in no way assure that I will be employed. 2 This application was completed by me; all entries on it and information in it are true and complete to the best of my knowledge and any misrepresentations of information given shall be considered an act of dishonesty subjecting me to disqualification or discharge. I will furnish freely such information or documents that may be required to complete my employment file. 3 In consideration of my being considered for employment and or being employed I hereby agree to submit to physical examination and tests as may be required by the Company, and I do hereby (1) grant release and assign unto United Road Towing, Inc. all rights, title and interest that I may subsequently acquire in all records and reports arising out of or in connection with said examinations and tests and (2) waive all rights to be advised on the content of said records and reports or to receive copies thereof, without prior written consent of United Road Towing, Inc. 4 If employed, I agree (1) to conform to the rules and regulations of United Road Towing, Inc. and (2) that my employment relationship with United Road Towing, Inc. voluntarily and acknowledge that there is no specified length of employment. Accordingly, either I or the company can terminate the relationship at will, for any reason, with or without cause, at any time. I further understand and agree that consistent with this policy of at-will employment, the Company can discipline, demote or suspend me or decrease my pay as it sees fit, at its sole and absolute discretion, with or without advance warning. I understand that the terms and conditions herein set forth may only be modified by written agreement jointly executed by myself and the President of the Company. 5 If employed, I do hereby grant United Road Towing, Inc., a nonexclusive right to practice any invention or device which I may conceive, develop or perfect using Company resources (such as time/or materials) during the period of my employment and to duplicate the invention or device as often as it may find occasion to do so in its business. I hereby authorize United Road Towing, Inc., or its agents (1) to investigate my previous record of employment to ascertain any and all information which may concern my record whether same is of record or not and I release my former employer from all liability for any damage on account of furnishing such information; (2) to investigate my previous scholastic record, and pursuant to the Family Educational Rights and Privacy Act of 1974, I authorize release of my education records by any educational agency or institution which I have attended; (3) to secure an investigative consumer report pursuant to Section 606 of the Fair Credit Reporting Act, including information as to my character, general reputation, personal characteristics and mode of living, whichever are applicable, provided that I may receive the name and address of the investigating consumer reporting agency from whom I may make a written request to receive full disclosure of any such investigative consumer report to receive same; and (4) to investigate my background and obtain such other information lawfully available to United Road Towing, Inc. as it deems appropriate and I release the supplier of such information from all liability for any damage that may result from releasing such information. Signature Date: United Road Towing, Inc. Equal Employment Opportunity Policy It is United Road Towing, Inc. s policy to select the best-qualified person for each position in the company. The Company will not discriminate against any applicant because of race, creed, color, religion, sex, age, national origin, handicap, marital status or veteran status. This policy applies to all employment practices and personnel actions. Recognizing the value of using human resources to their fullest, the Company has developed and instituted policies and procedures to ensure that it will (a) Recruit, hire, train and promote persons, in all job classifications without regard to age, race, color, religion, national origin, sex or physical or mental handicap, (b) Base decisions on employment to further the principal of equal employment opportunity ( c) Base promotion decisions on principles of equal opportunity by imposing only valid requirements for promotional opportunities. (d) Administer all personnel actions such as compensation, benefits, transfers, layoffs, returns from layoffs, terminations, and Company sponsored programs without regard to age, race, color, religion, national origin, sex or physical or mental handicap. (e) Maintain a nondiscriminatory job environment free of sexually harassing conduct. Approvals (For United Road Towing use only) Applicant - Do Not Write Below This Line Title Signature Date Title Signature Date Title Signature Date Hiring General Regional Manager Manager Manager All SG&A additions must be approved by the Regional Manager. This application is active for three (3) months and may be extended for one additional three-month period. The extension is to complete processing if United Road Towing, Inc. is unable to complete all elements of the hiring process within three (3) months. If extended, by your signature you authorize this application through enter date Signed Title
FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT AND AUTHORIZATION Disclosure It is United Road Towing's company policy to perform certain background checks of its employees and applicants. This may include checking your previous employment, criminal and civil history, drug/alcohol test records, educational records, driving records, credit, etc. The report may contain information on your character, general reputation, personal characteristics and mode of living. Thus you may be the subject of a consumer report or an investigative consumer report. The latter is obtained through personal interviews. We will use this information as part of the basis for our decision regarding your employment. This means that your former employers and others may be contacted and a search of public and private records made. We may not obtain this information without your express written consent. You do not have to consent; however, you will not be eligible for employment unless you agree to permit us to obtain this information. To help us obtain this information we sometimes use a consumer reporting agency. That agency is Concorde, Inc., 1835 Market Street, 12th Floor, Philadelphia, PA 19103, 215-563-5555 or 888-805-8885; www.concorde2000.com. In the event that we intend to make an adverse decision based on any information obtained, we will tell you and provide you with a copy of what we obtain; we will also provide a copy of your rights in the form prescribed by the Consumer Financial Protection Bureau. If you would like a copy of any report that we receive, you can obtain a copy by making that request to us in writing at this time. Acknowledgement and Authorization I acknowledge receipt of A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT. I authorize Company and Concorde to make lawful inquiries, including of my prior employers, and other entities and persons to verify my suitability for employment. This may include requests for information regarding my criminal, civil and motor vehicle records. I authorize the release of this information by any prior employer and anyone else having information or documentation about me to Company and Concorde. I authorize Concorde or other consumer reporting agencies to provide consumer and investigative consumer reports to you. I agree that so long as I remain employed by the above named employer, that this Disclosure and Authorization shall remain in effect; accordingly it shall not be necessary for me to sign a new Disclosure and Authorization. California, Minnesota and Oklahoma Applicants/Employees: Check the box if you want to receive a copy of any report California Applicants/Employees: By signing below, you also acknowledge receipt of a copy of the CALIFORNIA NOTICE REGARDING BACKGROUND INVESTIGATION New York Applicants/Employees: You have a right to receive a copy of any report by contacting Concorde directly. By signing below, you acknowledge receipt of a copy of New York Correction Law Article 23-A. Printed Name of Applicant/Employee Date of Birth Social Security Number Signature Date Telephone Number List Your Current Addresses - Street/City Zip List Your Former Addresses for Last 7 years - Street/City Zip List Your Former Addresses for Last 7 years - Street/City Zip A COPY OF THIS DOCUMENT MAY SERVE AS THE ORIGINAL
MANDATORY USE FOR ALL ACCOUNT HOLDERS IMPORTANT NOTICE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service 1. In connection with your application for employment with ( Prospective Employer ), Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA). When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report. When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act. The Prospective Employer cannot obtain background reports from FMCSA unless you consent in writing. If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below: 2. I authorize ( Prospective Employer ) to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am consenting to the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee. 3. I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I am challenging crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication. 4. Please note: Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report. I have read the above Notice Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this consent form, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above. Date: Signature Name (Please Print) NOTICE: This form is made available to monthly account holders by NICT on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant s written or electronic consent prior to accessing the Applicant s PSP report. Further, account holders are required by FMCSA to use the language provided in paragraphs 1-4 of this document to obtain an Applicant s consent. The language must be used in whole, exactly as provided. The language may be included with other consent forms or language at the discretion of the account holder, provided the four paragraphs remain intact and the language is unchanged. LAST UPDATED 10/29/2012
ALCOHOL AND/OR DRUG TEST NOTIFICATION Part 382 - Controlled Substances and Alcohol Use Testing applies to employees of this company. 382.113 Requirement for notice. Before performing an alcohol or controlled substances test under this part, each employer shall notify a driver that the alcohol or controlled substances test is required by this part. No employer shall falsely represent that a test is administered under this part. Company Name: Driver/Applicant Name: (Print) (First, M.I., Last) You are hereby notified the following test will be administered in compliance with the Federal Motor Carrier Safety Regulations. 1. The test is scheduled: Date: Location: Time: 2. Check type of test: 3. Check reason for test: Alcohol Pre-employment Post-accident Controlled Substance Random Reasonable suspicion/cause Return to duty Follow-up 4. Appointment instructions/comments: I understand as a condition of my employment with this company, the above identified test is required. Driver/Applicant's Signature Date Witnessed by: Company Representative Date Copyright 2001 Published by J.J. KELLER & ASSOCIATES, INC. Neenah, WI 54957-0368 www.jjkeller.com RETAIN IN EMPLOYEE'S CONFIDENTIAL FILE 375-F (Rev. 7/01)