EMPLOYMENT OPPORTUNITIES EMPLOYMENT APPLICATION PERSONAL First Name Middle Name Last Name Address City State Zip Email Phone Best Time to Call Today's Date Referred By Position Applied For EDUCATION High School High School Name and Location High School Graduate YesNoGED College College Name and Location College Areas of Study College Graduate YesNo College Degree Post High School/Technical Training Post High School/Technical Training Name and Location Post High School/Technical Training Areas of Study Post High School/Technical Training Graduate YesNo Post High School/Technical Training Degree WORK AVAILABILITY On what date would you be available for work? Are you currently on a "lay-off" status and subject to recall? YesNo Applying for Full TimePart TimeShift WorkTemporary Days available for work MondayTuesdayWednesdayThursdayFridaySaturdaySunday Are you at least 18 years of age? YesNo JOB RELATED SKILLS Truck Driving Experience Type Truck Driving Experience Years Equipment Operating Experience Type Equipment Operating Experience Years Other, ie Computers, Software Experience Type Other Experience Years DRIVER'S LICENSE INFORMATION Do you have a valid driver's license? YesNo Class (please select one) ABCD Do you have a Medical Examiner's Certificate? YesNo If Yes, Date of Expiration CDL YesNo Hazmat YesNo Tanker YesNo Driver's License Number State of Issue CERTIFICATIONS Are you CPR Certified? YesNo Date Certificate Expires Are you First Aid Certified? YesNo Date Certificate Expires Are you MSAH Certified? YesNo Hours of OSHA Training Date of OSHA Training PHYSICAL HISTORY Do you have any physical conditions which may limit your ability to perform the job applied for? YesNo If yes, please explain What can be done to accommodate your limitation? Would you be willing to take a physical examination? YesNo PRE-EMPLOYMENT DRUG TESTS WILL BE CONDUCTED REFERENCES Include only individuals familiar with your work experience. Do not include relatives. 1. Name Position Company Address Phone Years Known 2. Name Position Company Address Phone Years Known MILITARY SERVICE EXPERIENCE Duties Discharge Date Are you a Special Disabled Veteran? YesNo Are you a Vietnam Era Veteran? YesNo EMPLOYMENT HISTORY Are you currently employed? YesNo May we contact your present employer? YesNo 1. Previous Employer Employer Start Date End Date Phone Address Job Title Duties City, State Supervisor's Name Starting Pay Final Pay Reason For Leaving 2. Previous Employer Employer Start Date End Date Phone Address Job Title Duties City, State Supervisor's Name Starting Pay Final Pay Reason For Leaving APPLICANT'S STATEMENT "I certify that all the information submitted by me on this application is true and complete, and I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected and, if I am employed, my employment may be terminated at any time In consideration of my employment, I agree to conform to the company’s rules and regulations, and I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company’s option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice, at any time by the company. I understand that no company representative, other than its President, and then only when in writing and signed by the President, has any authority to enter into any agreement for employment for any specific period of time, or to may any agreement contrary to foregoing." Applicant's Signature (Please type full name here.) Date Δ
