Step 1 of 6 16% Application Name*Date of Application* Date Format: 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* Date Format: 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 ForLast NameFirst NameMiddle NameSocial 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 AddressesStreetCityState & Zip CodeHow Long? yr./mo.StreetCityState & Zip CodeHow Long? yr./mo.StreetCityState & Zip CodeHow Long? yr./mo.Do you have the legal right to work in the United States?YesNoDate of Birth Date Format: MM slash DD slash YYYY (Required for Commercial Drivers)Can you provide proof of age?Have you worked for this company before?YesNoWhere?Date (From) Date Format: MM slash DD slash YYYY Date (To) Date Format: MM slash DD slash YYYY Rate of PayPositionReason for leavingAre you now employed?YesNoIf not, how long since leaving last employment?Who referred you?Rate of pay expectedHave you ever been bonded?YesNo(Answer only if a job requirement)Name of bonding companyHave you ever been convicted of a felony?YesNoIf 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]?YesNoIf 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 NameAddress Street Address City State / Province / Region ZIP / Postal Code Contact PersonPhone NumberDate (From) Date Format: MM slash DD slash YYYY Date (To) Date Format: MM slash DD slash YYYY Position HeldSalaray/WageReason for leavingWere you subject to the FMCSRs✝ while employed?YesNoWas 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?YesNoEmployer NameAddress Street Address City State / Province / Region ZIP / Postal Code Contact PersonPhone NumberDate (From) Date Format: MM slash DD slash YYYY Date (To) Date Format: MM slash DD slash YYYY Position HeldSalaray/WageReason for leavingWere you subject to the FMCSRs✝ while employed?YesNoWas 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?YesNoEmployer NameAddress Street Address City State / Province / Region ZIP / Postal Code Contact PersonPhone NumberDate (From) Date Format: MM slash DD slash YYYY Date (To) Date Format: MM slash DD slash YYYY Position HeldSalaray/WageReason for leavingWere you subject to the FMCSRs✝ while employed?YesNoWas 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?YesNo *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 DateNature of Accident(HEAD-ON, REAR-END, UPSET, ETC.)FatalitiesInjuriesHazardous Material SpillNext Previous DateNature of Accident(HEAD-ON, REAR-END, UPSET, ETC.)FatalitiesInjuriesHazardous Material SpillNext Previous DateNature of Accident(HEAD-ON, REAR-END, UPSET, ETC.)FatalitiesInjuriesHazardous Material SpillTRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE LocationDateChargePenaltyLocationDateChargePenaltyLocationDateChargePenalty EXPERIENCE AND QUALIFICATIONS – DRIVER List all driver licenses or permits held in the past 3 years StateLicense No.TypeExpiration Date Date Format: MM slash DD slash YYYY StateLicense No.TypeExpiration Date Date Format: MM slash DD slash YYYY StateLicense No.TypeExpiration Date Date Format: MM slash DD slash YYYY Have you ever been denied a license, permit or privilege to operate a motor vehicle?YesNoIf the answer is YES, please give detailsHas any license, permit or privilege ever been suspended or revoked?YesNoIf the answer is YES, please give details DRIVING EXPERIENCE CHECK YES OR NOSTRAIGHT TRUCKYesNoType of EquipmentDate (From) Date Format: MM slash DD slash YYYY Date (To) Date Format: MM slash DD slash YYYY Approx No. Of Miles (Total)TRACTOR AND SEMI-TRAILERYesNoType of EquipmentDate (From) Date Format: MM slash DD slash YYYY Date (To) Date Format: MM slash DD slash YYYY Approx No. Of Miles (Total)TRACTOR - TWO TRAILERSYesNoType of EquipmentDate (From) Date Format: MM slash DD slash YYYY Date (To) Date Format: MM slash DD slash YYYY Approx No. Of Miles (Total)TRACTOR - THREE TRAILERSYesNoType of EquipmentDate (From) Date Format: MM slash DD slash YYYY Date (To) Date Format: MM slash DD slash YYYY Approx No. Of Miles (Total)MOTORCOACH - SCHOOL BUSYesNoMore than 8 passengersDate (From) Date Format: MM slash DD slash YYYY Date (To) Date Format: MM slash DD slash YYYY Approx No. Of Miles (Total)MOTORCOACH - SCHOOL BUSYesNoMore than 15 passengersDate (From) Date Format: MM slash DD slash YYYY Date (To) Date Format: MM slash DD slash YYYY Approx No. Of Miles (Total)OtherLIST 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 COMPANYLIST 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. SignatureDate Date Format: MM slash DD slash YYYY CAPTCHA
