Employment Opportunities "*" indicates required fields What position are you applying for?* Date of Application* MM slash DD slash YYYY Name* First Middle Last Phone*Email* Date of Birth* MM slash DD slash YYYY Social Security Number* Emergency Contact First Last Emergency Contact PhoneDate available to begin work:* MM slash DD slash YYYY Do you have legal right to work in the United States?* Yes No Residency History*List your addresses for the past 3 years:AddressHow Long? Add RemoveHave you ever worked for this company before?* Yes No How did you hear about our company? Education HistoryPlease check the highest level completed: High School Associate Degree Bachelor's Degree Some College Other Do you currently have a DOT Health Card? Yes No Have you attended any truck driving school? Yes No If Yes, please provide name of school and dates attended:Name of SchoolDates Attended Add RemoveHave you completed any safety driving or defensive driving programs such as the Smith System? Yes No If Yes, please list the course and date taken:Name of CourseDate Add RemoveList any other certifications or professional licenses held: Add RemoveDriving ExperienceList all classes of equipment (Straight Truck, Tractor & Semi Trailer, Tractor & 2 Trailers, Motor Coach, School Bus, etc.) that you have experience with.Class of EquipmentDatesApprox # of Miles (Total) Add RemoveDriving ExperienceList all states that you have operated in for the last 5 years. Add RemoveDriving ExpierenceList any special courses and /or training you have completed. (PD/ DDC/ Haz Mat/ etc.) Add RemoveDriving ExperienceList any Safe Driving Awards you hold and from whom.Safe Driving AwardIssued by: Add RemoveAccident Record for the past 3 years, write “NONE” if applicable.List the Date of Accident, Nature of Accident (Head on, Rear end, etc.), Location of Accident, Number of Injuries and Number of fatalities. Please include CMV and Non- CMV accidents.DateNatureLocation# Injuries# Fatalities Add RemoveTraffic Convictions for the past 3 years, write “NONE” if applicable.DateLocationChargePenalty Add Remove1. Have you ever been denied a license, permit, or privilege to operate a motor vehicle?* Yes No 2. Has any license, permit, or privilege ever been suspended or revoked?* Yes No 3. Is there any reason you might be unable to perform the functions of the job for which you are applying for (as described in the job description)?* Yes No 4. Have you ever been convicted of a felony?* Yes No If any of the answers to 1-4 are “YES”, give details: Add RemoveLICENSE INFORMATIONNo person who operates a commercial motor vehicle shall at any time have more than one driver’s license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below. Include all licenses held for the past 3 years.StateLicense #TypeEndorsementsExpiration Date Add RemoveEmployment HistoryBegin with most recent employer. Give a complete record of all employment in past 3 years regardless of nature and all driving employment in past 10 years. All fields must be filled in completely. *The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone who operates a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) has a GVWR or weighs 10,001 pounds or more, (2) is designated or used to transport nine or more passengers, or (3) is any size, used to transport hazardous materials in a quantity requiring placarding.EmployerAddressPositionSalary / WageContact / PositionPhone #DatesReason for leaving Add RemoveEmployment HistoryBegin with most recent employer. Give a complete record of all employment in past 3 years regardless of nature and all driving employment in past 10 years. All fields must be filled in completely. *The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone who operates a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) has a GVWR or weighs 10,001 pounds or more, (2) is designated or used to transport nine or more passengers, or (3) is any size, used to transport hazardous materials in a quantity requiring placarding.EmployerAddress Add RemovePosition HeldSalary / Wage Add RemoveContact / PositionPhone # Add RemoveDates EmployedFromTo Add RemoveReason for Leaving Were you subject to the FMCSRs* while employed here? 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 Personal / Work ReferencesList at least 3 personal and / or work references.NamePhone Number Add RemoveTO BE READ AND SIGNED BY APPLICANT*I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. 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 also understand that I am required to abide by all rules and regulations of the Company. I understand that the information I provide regarding my current and/or prior 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. 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 resend 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. Motor Vehicle Record Release Authorization Form To: The State Department of Transportation The undersigned does hereby authorize the release and delivery of all motor vehicle driving records relating to the undersigned, including but not limited to personal information to my employer and insurance agent. All Care Towing Inc. 1100 N 6 Street, St. Cloud, MN 56303 320-253-5203 ---------------------------------------------------------------- Robertson Ryan and Associates, Inc. Insurance Agency Agent: Skip Bargielski 1-800-258-0277 This authorization shall continue in effect until revoked by the undersigned in a subsequent writing delivered to you. This certifies 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.Applicant signatureBy filling in the your name below, you agree for it to be used as an electronic signature. First Last Δ
