|
Applicant Information |
| In
compliance with Federal and State Equal Employment Opportunity (EEO) laws,
qualified applicants are considered for all positions without regard to
race, color, religion, sex, national origin, age, marital status, or
non-job related disability. |
| Full Name: |
|
SS#:
(Ex: 999887777) |
| Phone: |
(Ex: 9045556789) |
Cellular
Phone:
(Ex: 9045556789) |
| Date of Birth: |
(Ex: 08/23/1956) |
Email
Address:
|
|
List your
addresses of residency for the past 3 years: |
| Address: |
|
City, State &
Zip:
Months:
|
| Previous Address: |
|
City, State &
Zip:
Months:
|
| Previous Address: |
|
City, State &
Zip:
Months:
|
| Do you have a
DWI or DUI on your Driver record at any time in the past?
|
Have you ever
been convicted of a crime?
|
| If so, give
date of DUI:
(Ex: 08/23/1956) |
If so,
explain the crime:
(max length 145) |
| Have you ever
tested positive on a DOT drug or alcohol test, pre-employment or
otherwise?
|
Are you
employed now?
|
| If so,
give date of drug test:
(Ex: 08/23/1956) |
If so, may we
inquire of present employer?
|
|
Emergency
Contact Information: |
| Name: |
|
Relationship:
|
| Phone: |
|
Workplace:
|
| Who referred
you to Pritchett Trucking?
|
|
Employment History |
| Please
complete with your previous 10 years work history, starting with your most
recent employer. Cover all time for the last 10 years. If you
were unemployed for more than 30 days, indicate each of those time periods
in one of the employer boxes. |
|
Employer
1 |
Dates |
| Name: |
|
From |
To |
| Address: |
|
Month:
|
Month:
|
| City, State & Zip: |
|
Year:
|
Year:
|
| Contact Person: |
|
Position Held:
|
| Phone Number: |
|
Salary/Wage:
|
| Were you
subject to the FMCSRs while employed:
|
Reason For
Leaving:
|
| Was your job
designated as a safety-sensitive function in any DOT-regulated mode
subject to the drug and alcohol testing requirements of 49 CFR Part 40?
|
|
Employer
2 |
Dates |
| Name: |
|
From |
To |
| Address: |
|
Month:
|
Month:
|
| City, State & Zip: |
|
Year:
|
Year:
|
| Contact Person: |
|
Position Held:
|
| Phone Number: |
|
Salary/Wage:
|
| Were you
subject to the FMCSRs while employed:
|
Reason For
Leaving:
|
| Was your job
designated as a safety-sensitive function in any DOT-regulated mode
subject to the drug and alcohol testing requirements of 49 CFR Part 40?
|
|
Employer
3 |
Dates |
| Name: |
|
From |
To |
| Address: |
|
Month:
|
Month:
|
| City, State & Zip: |
|
Year:
|
Year:
|
| Contact Person: |
|
Position Held:
|
| Phone Number: |
|
Salary/Wage:
|
| Were you
subject to the FMCSRs while employed:
|
Reason For
Leaving:
|
| Was your job
designated as a safety-sensitive function in any DOT-regulated mode
subject to the drug and alcohol testing requirements of 49 CFR Part 40?
|
|
Employer
4 |
Dates |
| Name: |
|
From |
To |
| Address: |
|
Month:
|
Month:
|
| City, State & Zip: |
|
Year:
|
Year:
|
| Contact Person: |
|
Position Held:
|
| Phone Number: |
|
Salary/Wage:
|
| Were you
subject to the FMCSRs while employed:
|
Reason For
Leaving:
|
| Was your job
designated as a safety-sensitive function in any DOT-regulated mode
subject to the drug and alcohol testing requirements of 49 CFR Part 40?
|
|
Employer
5 |
Dates |
| Name: |
|
From |
To |
| Address: |
|
Month:
|
Month:
|
| City, State & Zip: |
|
Year:
|
Year:
|
| Contact Person: |
|
Position Held:
|
| Phone Number: |
|
Salary/Wage:
|
| Were you
subject to the FMCSRs while employed:
|
Reason For
Leaving:
|
| Was your job
designated as a safety-sensitive function in any DOT-regulated mode
subject to the drug and alcohol testing requirements of 49 CFR Part 40?
|
|
Employer
6 |
Dates |
| Name: |
|
From |
To |
| Address: |
|
Month:
|
Month:
|
| City, State & Zip: |
|
Year:
|
Year:
|
| Contact Person: |
|
Position Held:
|
| Phone Number: |
|
Salary/Wage:
|
| Were you
subject to the FMCSRs while employed:
|
Reason For
Leaving:
|
| Was your job
designated as a safety-sensitive function in any DOT-regulated mode
subject to the drug and alcohol testing requirements of 49 CFR Part 40?
|
|
Driver License Information |
| List the valid
operating license in your possession: |
| CDL Class:
State:
Number:
Expiration Date:
(Ex: 07/24/1999) |
| Have you ever
lost your driving privileges?
Haz/Mat Endorsement:
|
| If so,
explain why you lost your driving privileges:
(max length is 134) |
|
Driving Violations |
| List below all
moving violations you have received in the past 3 years: |
| Date
(Ex: 08/23/1956) |
Offense |
Location |
Type of Vehicle |
|
|
|
|
|
|
|
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|
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|
Traffic Accidents |
| Date
(Ex: 08/23/1956) |
Nature of Accident |
Fatalities |
Personal Injury |
|
|
|
|
|
|
|
|
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|
|
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|
Experience |
| Explain
experience you have driving. If you have operated motor vehicle
equipment, explain the types and name of states driven in. |
|
(max length is 185) |
|
Comments |
| Please list
any comments or information you think we need for considering your
application: |
|
(max length is 250) |
|
Acknowledgment |
| This certifies
this online application was completed by me and that all entries on it and
information in it are true and complete to the best of my knowledge.
I authorize you to make such investigations and inquiries of my personal,
employment, financial or medical history and other related matters as may
be necessary in arriving at an employment decision. (Generally
inquiries regarding medical history will be made only if and after a
conditional offer of employment has been extended.) I hereby release
employers, schools, health care providers and other persons from all
liability in responding to inquiries and releasing information in
connection with my application. In the event of employment, I
understand that false or misleading information given in my application or
interview may result in discharge. I understand, also, that I am
required to abide by all rules and regulations of Pritchett Trucking. |
|
Date:
(Ex: 08/23/1956) |
Your
Initials:
|
Online
Application for Employment