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Driver's Application for Employment

Applicant Name:	Date of Application:
Email:	Company:

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.

TO BE READ AND AGREED TO BY APPLICANT

I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to:

Review information provided by previous employers;
Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and
Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.

has read and agreed

FOR COMPANY USE

PROCESS RECORD

APPLICANT HIRED _____________________	REJECTED _______________________
DATE EMPLOYED ______________________	POINT EMPLOYED ____________________
DEPARTMENT _______________________	CLASSIFICATION ______________________

SIGNATURE OF INTERVIEWING OFFICER ____________________________

TERMINATION OF EMPLOYMENT

DATE TERMINATED ____________________ DEPARTMENT RELEASED FROM _____________________

DISMISSED ____________________ VOLUNTARILY QUIT ______________ OTHER ________________

TERMINATION REPORT PLACED IN FILE _______________ SUPERVISOR __________________________

This form is made available with the understanding that J. J. Keller & Associates, Inc. is not engaged in rendering legal, accounting, or other professional services. J. J. Keller & Associates, Inc. assumes no responsibility for the use of this form, or any decision made by an employer which may violate local, state, or federal law.

APPLICANT INFORMATION

Position(s) Applied for:
Name:	Social Security No:
Date of Birth:	Can you provide proof of age?
Do you have the legal right to work in the United States?

List your addresses of residency for the past 3 years.

Current Address:

How Long?

Previous Addresses:

Have you worked for this company before?

Where?	Position:
From:	To:
Reason for Leaving:

Rate of pay expected:

Who referred you?

Have you ever been bonded?

Name of bonding company:

Can you perform, with or without reasonable accommodation, the essential functions of the job [as described in the attached job description]?

EMPLOYMENT HISTORY

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state and zip code.

Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years' information on those employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)

ACCIDENT RECORD

Accident record for the past 3 years or more.

TRAFFIC CONVICTIONS

Traffic convictions and forfeitures for the past 3 years (other than parking violations).

EXPERIENCE AND QUALIFICATIONS - DRIVER

Enter any driver licenses or permits held in the past 3 years.

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

IF THE ANSWER TO A IS YES, GIVE DETAILS:

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

IF THE ANSWER TO B IS YES, GIVE DETAILS:

DRIVING EXPERIENCE

Please include all classes of equipment you have driven. Please note you can add multiple classes.

Select all states operated in for the last five years:

Show special courses or training that will help you as a driver:

Which safe driving awards do you hold and from whom?

EXPERIENCE AND QUALIFICATIONS - OTHER

Show any trucking, transportation or other experience that may help in your work for this company:

List courses and training other than shown in elsewhere in this application:

List special equipment or technical materials you can work with (other than those already shown):

EDUCATION

Select the highest grade completed.

Elementary/Middle:

High School:

College:

Last school attended:

Address:

TO BE READ AND SIGNED BY THE APPLICANT

This certifies that this 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.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

August 11, 2021 9:26 pm PDT

Driver's Application for Employment Uploaded by Rebel Oil - noreply@rebeloil.com IP 45.51.98.15