Please list your employment record for the past 10 years.*
For each employer, please include: Start and End Dates of Employment, Company, Supervisor, Address, Telephone, City, State, Zip, Position Held, Rate of Pay, Driving Experience, Equipment Driven, Reason for Leaving and any other relevant information.
List all licenses held in the past 5 years *
Please include: Issuing State, License Number, Type, Expiration Date, Restrictions, Turned In?
If yes, list all traffic violations except for parking tickets for the last 4 years *
Please include: Month/Year, Violation, Type of Vehicle, Location, City/State, Penalty/Fine, Points Assessed
If yes, list all accidents, preventable, non-preventable, regardless of $$ amount or fault in the past 4 years. *
Please include: Month/Year, Type of accident, Type of Vehicle, Location, City/State, $$ Amount of Damages, Number of Fatalities, Number of Injuries, Were you ticketed, Were you at fault
If yes, list all claims, preventable, non-preventable, regardless of $$ amount or fault in the past 4 years. *
Please include: Month/Year, Type of Claim, $$ Amount of Claim, Type of Cargo, Were you charged for the claim
I hereby acknowledge that prior to submitting this application, I have been informed that the information provided herein may be used to conduct current and previous employer’s references or any other individuals this Company considers necessary.
I hereby authorize my current and previous employers, references, and any other individuals contacted by this company to release any past or present information requested, including but not limited to past drug and alcohol test results, and I release all providers of said information from any liability stemming from release of same information.
In connection with my application for employment with this Company, I understand that I have the right to review, correct or rebut any information obtained from former employers requested by this Company.
I understand that any false, misleading, or incomplete answers or statements shall be considered sufficient cause for denial or termination of employment and/or authorization to drive.
I understand that nothing contained in this application or in the granting of an interview or a road test is intended to create an employment contract between this Company and myself, for either employment, authorization to drive, or for the providing of any benefits. No promises regarding employment or authorization to drive have been made to me, and no such promises exist unless specifically made by this Company in writing. If an employment relationship is established, I understand that, as an employee at will, I have the right to terminate my employment at any time, and this Company has the same right.
Signature*
By typing your name into this field you understand that this will serve as your digital signature.