Employment Application (2-Pp.) s7

EMPLOYMENT APPLICATION- Please list up to 10 years prior experience

APPLICANT INFORMATION

Last Name First M.I. Date

Street Address Apartment/Unit #

City State ZIP

Phone E-mail Address

Date Available Desired Salary

Position Applied for

Are you at least 18 years of age: SS #:

Have you worked for this company before? Who referred you?

Are you a citizen of the United States? YES NO If no, are you authorized to work in the U.S.? YES NO

Have you ever worked for this company? YES NO If so, when?

Have you ever been convicted of a felony? YES NO If yes, explain

EDUCATION

High School Address

From To Did you graduate? YES NO Degree

College Address

From To Did you graduate? YES NO Degree

Other Address

From To Did you graduate? YES NO Degree PREVIOUS EMPLOYMENT

Company Phone

Address Supervisor

Job Title Starting Salary $ Ending Salary $

Responsibilities

From To Reason for Leaving May we contact your previous supervisor YES NO for a reference? Company Phone

Address Supervisor

Responsibilities

From To Reason for Leaving May we contact your previous supervisor YES NO for a reference? Company Phone

Address Supervisor

Responsibilities

From To Reason for Leaving May we contact your previous supervisor YES NO for a reference? MILITARY SERVICE

Branch: From To

Rank at Discharge Type of Discharge If other than honorable, explain 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 pervious 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 382.413, 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations.

______Applicant’s signature Date of Birth

______Print Name SS#

______Date

For Driver Applicants Only: TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)

LOCATION DATE CHARGE PENALTY

Do you have any experience operating a manual transmission? Y N

If yes please give extent of experience:______

DISCLAIMER AND SIGNATURE

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Signature Date Information Needed From DOT Driver Applicants

 Copy of Current MVR- not older than 30 days

 Copy of CURRENT Class A CDL

 Appropriate endorsements (T,X)

 Hazmat Training records if applicable

 Copy of current medical card

 Copy of social security card

 Copy of T.W.I.C. card

 Application including the past 10 years of work history INVESTIGATIONS AND INQUIRIES

TO: ______Date:______Address: ______FROM: ______Phone ______Address: ______

Applicant: ______SS#______CDL# ______Address: ______ST____ Zip Code______Job Applied for: ______CDL DRIVER______1. Applicant list dates of employment with your firm from:______to:______2. Is this correct: _____Yes _____No _____ Full Time______Part Time ______3. Type of equipment driven: _____Semi _____St. Truck _____Twins _____Bus 4. Was individual involved in any preventable accident? _____Yes _____No 5. To your knowledge, was license ever suspended? _____Yes _____No 6. Did applicant remain DOT qualified during their employment with you?_____Yes____No 7. Was their conduct satisfactory? _____Yes _____No _____Other______8. Was the applicant attendance record ______Acceptable ______Unacceptable. 9. Why did applicant leave? _____Resign _____Discharge _____Layoff 10. Would you re-employ this applicant? _____Yes _____No. 11. Comments:______Applicant and Employer’s must exchange the following information as required by Parts 391.23, Part 40 and Part 382 of the FMCSR’s. We must request the following: 1. Has this individual had an alcohol test with a confirmed BAC of 0.04 or greater in the past three years? ☐ Yes ☐ No 2. Did applicant have a verified positive drug test in past 3 years? ☐ Yes ☐ No 3. Did applicant refuse testing (including verified adulterated or substituted drug test results in the past 3 years? ☐ Yes ☐ No 4. Has the individual violated other DOT drug/alcohol regulations in the last 3 years? ☐ Yes ☐ No 5. Have you received information from a previous employer that this individual violated FMCSR’s Part 382 or Part 40 in the last 3 years? ☐ Yes ☐ No

Signature: ______DATE:______

Title of Person Supplying Information ______WAIVER I hereby authorize my previous employer named above to release all information concerning my employment, including job performance, ability and fitness, and alcohol and controlled substance testing results. I hereby release my previous employer from any and all liability of any type as a result of providing the above information to the named prospective employer.

Applicant ______Witness ______(Signature) (Signature)

MATC Form 1001, Rev. 06/07/05