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Application for Employment

Date*

First Name*

Middle Name*

Last Name*

Social Security Number*

Date of Birth*

Daytime Phone*

Evening Phone*

Mobile Number*

List Present Address*

List Past Address*

In case of emergency, contact (name, relationship and telephone number)*

Education High School*

Education / College, University, Tech School...*

Education Other*

Professional Licenses / List the name, number, year, and expiration date of any professional licenses you hold*

Skills - Knowledge Level / Office Machines, Industry Software, MS Products (Enter DNA if not applying for an office position)*

Accident record for the last 3 years / Year - Nature of Accident - Head-On, Rear-End, Upset - Fatalities - Injuries*

If you enter YES to Fatalities or Injuries please explain / If you answered NO enter DNA*

Traffic convictions and forfeitures for the past 3 years (other than parking tickets) List - Location / Date / Charge / Penalty*

Driving Experience - Sedan - List form date / List to date / List approximate number of miles driven (Enter DNA if not applying for driving job)*

Driving Experience - BUS - List form date / List to date / List approximate number of miles driven (Enter DNA if not applying for driving job)*

Driving Experience - Truck - List form date / List to date / List approximate number of miles driven (Enter DNA if not applying for driving job)*

Last Employer Name , Address, Job title, Duties, Reason for leaving, Supervisor Name, Employed to/from dates, Beginning Salary and Ending salary*

Second Last Employer Name , Address, Job title, Duties, Reason for leaving, Supervisor Name, Employed to/from dates, Beginning Salary and Ending salary*

Third to Last Employer Name , Address, Job title, Duties, Reason for leaving, Supervisor Name, Employed to/from dates, Beginning Salary and Ending salary*

Fourth to Last Employer Name , Address, Job title, Duties, Reason for leaving, Supervisor Name, Employed to/from dates, Beginning Salary and Ending salary*

List memberships in professional organizations and/or associations.*

List any professional, academic, or civic awards or honors you have received.*

List at least three persons un-related including name, address and phone number*

Have you tested positive or refused a pre-employment drug and alcohol screening in the last 2 years
YesNo

Have you ever been denied a license, permit or privilege to operate a motor vehicle?
YesNo

Any Fatalities
YesNo

Any Injuries
YesNo

Has any license, permit or privilege ever been suspended or revoked?
YesNo

Employment Record / List most recent employment first. I understand that DOT requires that employment for the last 3 years and/or commercial driving experience for the past 10 years be shown.
YesNo

Have you ever been convicted of a Felony?
YesNo

I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous employment and any pertinent information.
YesNo

I understand and agree that, if hired, my employment is for wages and salary and may be terminated at any time without prior notice and without cause.
YesNo

I certify that the facts contained in this application are true and complete to the best of my knowledge. Falsified statements shall be grounds for dismissal.
YesNo