Application for Employment

 

Personal Information

 
 
 
 
 
 
 
 
 
 
 
Are You a U.S. Citizen?
 
 
 
 
 
 
 
 
Have You Ever Been Convicted of A Felony?
 
 
 
 
 
 
 
 
 
If Selected For Employment Are You Willing To Submit to a Pre-Employment Drug Screening Test?
 
 
 
 
 
 
 

Position

 
 
 
 
 
Employment Desired

Education

 
School Name
 
Location
 
Years Attended
 
Degree Received
 
Major
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Current & Previous 3 Years Addresses

 
Address
 
From
 
To
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Employment History

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Driving Experience / Certification

 
Class of Equipment
 
Approx Miles
 
From
 
To
 
 
Straight Truck
 
 
 
 
 
Tractor & Semi-Trailer(s)
 
 
 
 
 
Stick Shift?
 
 
 
 
 
 
 
 
 
 
 
 
Other (specify):
 
 
 
 
 
Physical Exam Expiration Date:
 
 
 
List states operated in, for the last five (5) years:
 
 
 
List special courses/training completed (PTD/DDC, HAZMAT, ETC):
 
 
 
List any Safe Driving Awards you hold and from whom:
 
 
Accident Record for past three (3) years (attach sheet if more space is needed):
 
Date of Accident
 
Location of Accident
 
# of Fatalities
 
# of People Injured
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Traffic Convictions and Forfeitures for the last three (3) years (other than parking violations):
 
Date
 
Location
 
Charge
 
Penalty
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Driver’s License (list each driver’s license held in the past three(3) years:
 
State
 
License
 
Type
 
Endorsements
 
Expiration Date
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
 
 
 
 
 
 
 
 
 
 
Has any license, permit or privilege ever been suspended or revoked?
 
 
 
 
 
 
 
 
 
 
Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the job description)?
 
 
 
 
 
 
 
 
 
 
Do you have any SR22 filings or other restrictions?
 
 
 
 
 
 
 
 
 
 
Have you ever been convicted of a felony?
 
 
 
 
 
 
 
 
 
If the answers to any questions listed above are “yes”, give details:
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.