Employment Application

Emergency Contact Information
Name *
Relationship *
Street Address *
City *
State *
Phone *
Alternate Phone
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, or the presence of a non job related medical condition or handicap.
Have you ever been denied a license, permit or privilege to operate a motor vehicle? *

Yes No
If yes, please explain *
Has any license, permit or privilege ever been suspended or revoked? *

Yes No
If yes, please explain *
Position applying for *
Rate of pay expected
Resumé (optional)

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Driver / Salesman questions (cont.)
Equipment Experience
Class of equipment *

Two-wheeler/dolly Manual pallet jack Electric pallet jack Fork-lift None
Brief description of experience with equipment selected above *

License Information
Section 383.21 FMCSR states "No person who operates a commercial motor vehicle shall at any time have more than one driver"s license. I certify that I do not have more than one motor vehicle license, the information for which is listed below.
Licensing state *
License # *
Type *
Restrictions
Expiration date *

- Month - Day Year
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Education &/or Formal Training
Highest education completed *
Last school attended *
City *
TO BE READ AND ACKNOWLEDGED BY APPLICANT
I authorize you to make sure investigations and inquiries to 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 current/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.
By selecting "Yes", I certify that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge.
Note: a motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.
Select One *

Yes No
Applicant's initials *
Today's date of application

- Month - Day Year
Date
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