Careers Form – Readydrill

Date

Select One

Name

First Middle Last

Phone

Emergency Phone

Relation

Age

Date of Birth

Social Security Number

Current Mail Address

Street Address City State / Province / Region ZIP / Postal Code

From

Education and Employment History

Highest High School Completed:

Graduated
GED
Did Not Graduated

Highest College Completed:

Some College
Associates
Bachelor's
None

Graduate School:

First Choice
Second Choice
Third Choice

Present or Last Employer

From

To

Company Name

Position Held

Address

Street City State Zip

Reason of Leaving

Phone

Supervisor's Name

Were you subject to the Federal Motor Carrier Safety Regulationg (FMCRS) while employed by the previous employer ?

Yes
No

Was the previous job position designated as a safety sensitive funtion in any DOT regulated mode,subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?

Yes
No

Past Employer

From

To

Company Name

Position Held

Address

Street Address City State / Province / Region ZIP / Postal Code

Reason of Leaving

Phone

Supervisor's Name

Were you subject to the Federal Motor Carrier Safety Regulationg (FMCRS) while employed by the previous employer ?

Yes
No

Was the previous job position designated as a safety sensitive funtion in any DOT regulated mode,subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40?

Yes
No

Explain any gap in employment

Experience

Class of Equipment

Date

Type of Equipment

Approximate Total Miles

Straight Truck

Tractor and Semi-Trailer

Tractor-Two Trailers

Other

List all states or foreign countries operated in for the last five years:

List all special courses/ training completed (Haz Mat,PTD/DDC/,etc):

Accident Record for the past three years(attach a sheet if more space id needed)

A. Have you ever been denied fa licences, permit or privilege to operate a Motor vehicle?

Yes
No

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

C. Have you ever been convicted of a felony?

Yes
No

D. Have you ever been tested positive or refused a DOT drug or alcohol pre-employment test within the past two years from an employer who did not hire you?

Yes
No

if the answer to A,B,C, or D is "Yes," please give details:

DOT physical exam Expiration Date:

PERSONAL REFERENCES

List three persons for references,other than family members, who have knowledge of your safety habits.

Name

Phone

Relationship

TO BE READ AND SIGNED BY APPLICANT

It is agreed and understood that any misrepresentation given on this application for qualification shall be considered and act of dishonesty and be grounds for immediate disqualification or termination without recourse.

I give the motor carrier and its agent or representatives the right to investigate all reterences and secure additional information about my employment background I hereby release from all liability for damages the motor carrier and its agents or representatives for seeking such information and all other persons, corporations organizations for furnishing such informations.

I agree to furnish such additional information and complete such examinations as may be required to complete my employment file.

It is agreed and understood that this application for qualification is no way obligates the motor carrier to employee me. It is agreed and understood that I will be on a 90-day probationary period during which I may be disqualified without recourse.

This certifies that this application was completed by me, and that all entries on it and inforamtion in it are true and complete to the best of my knowledge.

Applicant's Signature

Date

Remarks (FOR OFFICE USE ONLY)