Employment Information Sheet

WASTE Employment Information Sheet

Today’s Date ______

Position applied for: Manager ______Driver ______Hopper ______

Applicant Information Date of B i r t h Full Name: : Last First M.I.

Address: Street Address Apartment/Unit #

City State ZIP Code

Home Phone: Cell Phone:

E-mail: Date Available: ______

Social Security No. ______

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

Have you any medical YES NO issues? If yes, explain:

YES NO Married? YES NO Children? If yes, how many? Ages?

License Information Section 383.21 FMCSR states “No person who operates a commercial motor vehicle shall at any time have more than one driver’s license”. I clarify that I do not have more than one motor vehicle license, the information for which is below. State License No. Type Expiration Date

(Please provide us a copy of your current CDL and current medical card)

Driving Experience Class of Equipment Type of Equipment Dates Approx. No. of Miles (Total) (Van, Tank, Flat, Etc.) From To Straight Truck Tractor & Semi-Trailer Tractor – Two Trailers Other

Accident Record for Past Three (3) Years or More

(Attach Sheet If More Space Is Needed) Dates Nature of Accident Number of Number of Chemical Spills (Head-on, rear-end, upset, Etc.) Fatalities Injuries YES NO

YES NO

Traffic Convictions and Forfeitures for the Past Three (3) Years

(Other Than Parking Violations) Date Convicted Violation State of Violation Penalty (month/year) (forfeited bond, collateral and/or points)

(Attach Sheet If More Space Is Needed) YES Clean Driving Record:

If no, explain: YES Waste Truck Driving Experience: If yes, explain: (ie; company, where & years) YES NO NO Have you ever been denied a license, permit or privilege to operate a motor vehicle? If yes, explain: ______YES NO Has any license, permit or privilege ever been suspended or revoked?

YES NO If yes, explain: Any experience in waste supervision:

If yes, explain position: YES NO

Driving School:

If yes: Where?

Employment Record

(Attach Sheet If More Space Is Needed)

Last/Current Employer:

Company Name: Phone: Address: Supervisor: Job Title: Starting Salary:$ Ending Salary:$ Responsibilities: Reason for From: To: Leaving: Any gaps in employment and/or unemployment must be explained. Please include dates (Month/Year) and reason.

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while YES NO employed by the previous employer?

Was the previous job position designed as a safety sensitive function in any DOT regulation mode, subject to alcohol and controlled substances testing requirements YES NO as required by 49 CFR Part 40?

Prior Employer: Company Name: Phone: Address: Supervisor: Job Title: Starting Salary:$ Ending Salary:$ Responsibilities: Reason for From: To: Leaving: Any gaps in employment and/or unemployment must be explained. Please include dates (Month/Year) and reason.

Military Service Branch: From: To:

Rank at Discharge: Type of Discharge:

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. I understand, also, that I am required to abide by all rules and regulations of the Company.

Signature: Date: 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.

Signature: Date: Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.

YES I’LL COME BACK Can you pass a drug test today?