Construction Site & Land Development Services in Dallas/Fort Worth, TX

TO BE READ AND AGREED 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 a hiring 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 the following:

Review information provided by previous employers;
Have errors in the information provided 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.

Checkbox

Agree

ACCIDENT HISTORY

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE( ATTACH SHEET IF NECECESSRY) IF NONE, PLEASE WRITE NONE

DATE OF LAST ACCIDENT

NATURE OF ACCIDENT

FATALITIES

Yes

INJURIES

Yes

HAZARDOUS MATERIAL SPILL

Yes

DATE OF LAST ACCIDENT

NATURE OF ACCIDENT

FATALITIES

Yes

INJURIES

Yes

HAZARDOUS MATERIAL SPILL

Yes

DATE OF LAST ACCIDENT

NATURE OF ACCIDENT

FATALITIES

Yes

INJURIES

Yes

HAZARDOUS MATERIAL SPILL

Yes

EMPLOYMENT HISTORY

PROVIDE EMPLOYMENT FOR THE PAST 10 YEARS WITHOUT GAPS IN ACCORDANCE WITH PART 391.21 &23 OF THE FMCSR

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 must provide additional 7 years of information on employers for whom the applicant operated such vehicle.
(Start with the most recent employer)

EMPLOYER NAME

From Date

To Date

ADDRESS

POSITION HELD

SALARY/WAGE

CONTACT PERSON

PHONE NUMBER

REASON FOR LEAVING

WERE YOU SUBJECT TO THE FMCSR WHILE EMPLOYED

Yes

WAS YOUR .JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN /NY DOT-REGULATED MODE SUBJECT TO THE DRUG & ALCOHOL TESTING REQUJRMENTS OF 49 CFR PART 40?

Yes

II

EMPLOYER NAME

From Date

To Date

ADDRESS

POSITION HELD

SALARY/WAGE

CONTACT PERSON

PHONE NUMBER

REASON FOR LEAVING

WERE YOU SUBJECT TO THE FMCSR WHILE EMPLOYED

Yes

WAS YOUR .JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN /NY DOT-REGULATED MODE SUBJECT TO THE DRUG & ALCOHOL TESTING REQUJRMENTS OF 49 CFR PART 40?

Yes

III

EMPLOYER NAME

From Date

To Date

ADDRESS

POSITION HELD

SALARY/WAGE

CONTACT PERSON

PHONE NUMBER

REASON FOR LEAVING

WERE YOU SUBJECT TO THE FMCSR WHILE EMPLOYED

Yes

WAS YOUR .JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN /NY DOT-REGULATED MODE SUBJECT TO THE DRUG & ALCOHOL TESTING REQUJRMENTS OF 49 CFR PART 40?

Yes

IV

EMPLOYER NAME

From Date

To Date

ADDRESS

POSITION HELD

SALARY/WAGE

CONTACT PERSON

PHONE NUMBER

REASON FOR LEAVING

WERE YOU SUBJECT TO THE FMCSR WHILE EMPLOYED

Yes

WAS YOUR .JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN /NY DOT-REGULATED MODE SUBJECT TO THE DRUG & ALCOHOL TESTING REQUJRMENTS OF 49 CFR PART 40?

Yes

V

EMPLOYER NAME

From Date

To Date

ADDRESS

POSITION HELD

SALARY/WAGE

CONTACT PERSON

PHONE NUMBER

REASON FOR LEAVING

WERE YOU SUBJECT TO THE FMCSR WHILE EMPLOYED

Yes

WAS YOUR .JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN /NY DOT-REGULATED MODE SUBJECT TO THE DRUG & ALCOHOL TESTING REQUJRMENTS OF 49 CFR PART 40?

Yes

Vi

EMPLOYER NAME

From Date

To Date

ADDRESS

POSITION HELD

SALARY/WAGE

CONTACT PERSON

PHONE NUMBER

REASON FOR LEAVING

WERE YOU SUBJECT TO THE FMCSR WHILE EMPLOYED

Yes

WAS YOUR .JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN /NY DOT-REGULATED MODE SUBJECT TO THE DRUG & ALCOHOL TESTING REQUJRMENTS OF 49 CFR PART 40?

Yes

VII

EMPLOYER NAME

From Date

To Date

ADDRESS

POSITION HELD

SALARY/WAGE

CONTACT PERSON

PHONE NUMBER

REASON FOR LEAVING

WERE YOU SUBJECT TO THE FMCSR WHILE EMPLOYED

Yes

WAS YOUR .JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN /NY DOT-REGULATED MODE SUBJECT TO THE DRUG & ALCOHOL TESTING REQUJRMENTS OF 49 CFR PART 40?

Yes

VIII

EMPLOYER NAME

From Date

To Date

ADDRESS

POSITION HELD

SALARY/WAGE

CONTACT PERSON

PHONE NUMBER

REASON FOR LEAVING

WERE YOU SUBJECT TO THE FMCSR WHILE EMPLOYED

Yes

WAS YOUR .JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN /NY DOT-REGULATED MODE SUBJECT TO THE DRUG & ALCOHOL TESTING REQUJRMENTS OF 49 CFR PART 40?

Yes

Includes vehicles having a GYWR of26,00 I lbs. or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.
The Federal Motor Carrier Safety Regulations (FM CSR) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (I) weighs or has a GVWR of l 0,00 I pounds or more, (2) is designed • or used to transpo1t 9 or more passengers. OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

TRAFFIC CO'IIVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE: NONE

LOCATION

DATE

CHARGE

PENALTY

LOCATION

DATE

CHARGE

PENALTY

LOCATION

DATE

CHARGE

PENALTY

LOCATION

DATE

CHARGE

PENALTY

EXPERIENCE AND QUALIFICATIONS- DRIVER LIST ALL DRIVER LICENCES OR PERMITS HELD IN THE PAST 3 YEARS

DRIVER LICENSES

STATE

LICENSE NO.

TYPE

EXPIRATION DATE

STATE

LICENSE NO.

TYPE

EXPIRATION DATE

STATE

LICENSE NO.

TYPE

EXPIRATION DATE

STATE

LICENSE NO.

TYPE

EXPIRATION DATE

A. Have you ever been denied a license permit or privilege to operate a motor vehicle?

Yes

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

Yes

IF THE ANSWER TO ElTHER A OR B IS YES. PLEASE GIVE DETAILS

DRIVING EXPERIENCE CHECK: YES OR NO

DATES FROM ... TO ...

From

APPROX# or TOTAL MILES

Total miles

OTHER

LIST 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?

EDUCATION

SELECT HIGHEST GRADE COMPLETED:

HIGH SCHOOL:

LAST SCHOOL ATTENDED:

EXPERIENCE AND QUALIFICATIONS OTHER

SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY

LIST ANY COURSES OR TRAINING OTHER THAN SHOWN ON THIS APPLICATION

LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH OTHER THAN WHAT IS LISTED ON APPLICATION

This certifies that this application was completed by me and that all entries and information provided is true and complete to the best of
my knowledge.

If you are human, leave this field blank.

DRIVER'S APPLICATION FORM

TO BE READ AND AGREED BY APPLICANT

APPLICANT TO COMPLETE

ACCIDENT HISTORY

EMPLOYMENT HISTORY

II

III

IV

V

Vi

VII

VIII

TRAFFIC CO'IIVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE: NONE

EXPERIENCE AND QUALIFICATIONS- DRIVER LIST ALL DRIVER LICENCES OR PERMITS HELD IN THE PAST 3 YEARS

DRIVER LICENSES

DRIVING EXPERIENCE CHECK: YES OR NO

SELECT TYPE OF EQUIP.

DATES FROM ... TO ...

APPROX# or TOTAL MILES

EDUCATION

EXPERIENCE AND QUALIFICATIONS OTHER

817-597-8490