Step 1 of 6 16% Application Name* Date of Application* MM slash DD slash YYYY Company* Address* City* State* Zip* Phone Number*Email Address* 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 SIGNED BY APPLICANT 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(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company. 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. Signature* Date* MM slash DD slash YYYY 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 to Complete Position(s) Applied For Last Name First Name Middle Name Social Security No. List your addresses of residency for the past 3 years Current Address Street Address City State / Province / Region ZIP / Postal Code PhoneHow Long? yr./mo.Previous AddressesStreet City State & Zip Code How Long? yr./mo.Street City State & Zip Code How Long? yr./mo.Street City State & Zip Code How Long? yr./mo.Do you have the legal right to work in the United States? Yes No Date of Birth MM slash DD slash YYYY (Required for Commercial Drivers)Can you provide proof of age? Have you worked for this company before? Yes No Where? Date (From) MM slash DD slash YYYY Date (To) MM slash DD slash YYYY Rate of Pay Position Reason for leaving Are you now employed? Yes No If not, how long since leaving last employment? Who referred you? Rate of pay expected Have you ever been bonded? Yes No (Answer only if a job requirement)Name of bonding company Have you ever been convicted of a felony? Yes No If yes, please explain fully on a separate sheet of paper. Conviction of a crime is not an automatic bar to employment-all circumstances will be considered. Is there any reason you might be unable to perform the functions of the job for which you have applied [as described in the attached job description]? Yes No If yes, explain if you wish 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.) Employer Name Address Street Address City State / Province / Region ZIP / Postal Code Contact Person Phone NumberDate (From) MM slash DD slash YYYY Date (To) MM slash DD slash YYYY Position Held Salaray/Wage Reason for leaving Were you subject to the FMCSRs✝ while employed? Yes No 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? Yes No Employer Name Address Street Address City State / Province / Region ZIP / Postal Code Contact Person Phone NumberDate (From) MM slash DD slash YYYY Date (To) MM slash DD slash YYYY Position Held Salaray/Wage Reason for leaving Were you subject to the FMCSRs✝ while employed? Yes No 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? Yes No Employer Name Address Street Address City State / Province / Region ZIP / Postal Code Contact Person Phone NumberDate (From) MM slash DD slash YYYY Date (To) MM slash DD slash YYYY Position Held Salaray/Wage Reason for leaving Were you subject to the FMCSRs✝ while employed? Yes No 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? Yes No *Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding. ✝The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding. ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED) IF NONE, WRITE NONE Last Accident Date Nature of Accident (HEAD-ON, REAR-END, UPSET, ETC.)Fatalities Injuries Hazardous Material Spill Next Previous Date Nature of Accident (HEAD-ON, REAR-END, UPSET, ETC.)Fatalities Injuries Hazardous Material Spill Next Previous Date Nature of Accident (HEAD-ON, REAR-END, UPSET, ETC.)Fatalities Injuries Hazardous Material Spill TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE Location Date Charge Penalty Location Date Charge Penalty Location Date Charge Penalty EXPERIENCE AND QUALIFICATIONS – DRIVER List all driver licenses or permits held in the past 3 years State License No. Type Expiration Date MM slash DD slash YYYY State License No. Type Expiration Date MM slash DD slash YYYY State License No. Type Expiration Date MM slash DD slash YYYY Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No If the answer is YES, please give details Has any license, permit or privilege ever been suspended or revoked? Yes No If the answer is YES, please give details DRIVING EXPERIENCE CHECK YES OR NOSTRAIGHT TRUCK Yes No Type of Equipment Date (From) MM slash DD slash YYYY Date (To) MM slash DD slash YYYY Approx No. Of Miles (Total) TRACTOR AND SEMI-TRAILER Yes No Type of Equipment Date (From) MM slash DD slash YYYY Date (To) MM slash DD slash YYYY Approx No. Of Miles (Total) TRACTOR - TWO TRAILERS Yes No Type of Equipment Date (From) MM slash DD slash YYYY Date (To) MM slash DD slash YYYY Approx No. Of Miles (Total) TRACTOR - THREE TRAILERS Yes No Type of Equipment Date (From) MM slash DD slash YYYY Date (To) MM slash DD slash YYYY Approx No. Of Miles (Total) MOTORCOACH - SCHOOL BUS Yes No More than 8 passengersDate (From) MM slash DD slash YYYY Date (To) MM slash DD slash YYYY Approx No. Of Miles (Total) MOTORCOACH - SCHOOL BUS Yes No More than 15 passengersDate (From) MM slash DD slash YYYY Date (To) MM slash DD slash YYYY Approx No. Of Miles (Total) Other LIST STATES OPERATED IN FOR 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 ELSEWHERE IN THIS APPLICATIONLIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN) Education Primary SchoolLast School Attended (Primary School) City, State (Primary School) Highest Grade Completed (Primary School) High SchoolLast School Attended (High School) City, State (High School) Highest Grade Completed (High School) CollegeLast School Attended (College) City, State (College) Highest Grade Completed (College) TO BE READ AND SIGNED BY 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. Signature Date MM slash DD slash YYYY CAPTCHA Δ
