Employment Application - Lake City Trucking

APPLICATION INFORMATION

Name *

First

Middle

Last

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Phone *

Date of Birth *

Email *

Social Security #

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Date of Application *

Position Applied For *

Date Available for Work *

Do you have legal right to work in the United States? *

Yes
No

PREVIOUS THREE YEARS RESIDENCY

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Current Address *

Address Line 1

Address Line 2

City

State

Zip Code

Number of Years at this Address *

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Mailing Address (if different from current address)

Address Line 1

Address Line 2

City

State

Zip Code

Number of Years at this Address

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Address Line 2

City

State

Zip Code

Number of Years at this Address

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Address Line 2

City

State

Zip Code

Number of Years at this Address

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Address Line 2

City

State

Zip Code

Number of Years at this Address

LICENSE INFORMATION

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State *

Expiration Date *

License # *

Type/Class *

Endorsements *

Previously Held Licenses

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State

Expiration Date

License #

Type/Class

Endorsements

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State

Expiration Date

License #

Type/Class

Endorsements

DRIVING EXPERIENCE

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Class of Equipment

Type of Equipment

(Van, Tank, Flat, Etc.)

Date From/Date To

Approx. # of Miles (Total)

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Straight Truck

Tractor & Semi-Trailer

Tractor & 2 Trailers

Tractor & Tanker

Other

Type of Equipment

Date From/Date To

Approx. # of Miles (Total)

ACCIDENT RECORD FOR THE PAST 3 YEARS

Check this box if none

Check this box if none

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Date

(List most recent first)

Chemical Spills

Yes
No

Nature of Accident

(Head-on, rear-end, upset, etc.)

Number of Fatalities

Number of Injuries

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Date

(List most recent first)

Chemical Spills

Yes
No

Nature of Accident

(Head-on, rear-end, upset, etc.)

Number of Fatalities

Number of Injuries

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Date

(List most recent first)

Chemical Spills

Yes
No

Nature of Accident

(Head-on, rear-end, upset, etc.)

Number of Fatalities

Number of Injuries

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)

Check this box if none

Check this box if none

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Date

Violation

State of Violation

Penalty

(Forfeited bond, collateral and/or points)

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Date

Violation

State of Violation

Penalty

(Forfeited bond, collateral and/or points)

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Date

Violation

State of Violation

Penalty

(Forfeited bond, collateral and/or points)

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Date

Violation

State of Violation

Penalty

(Forfeited bond, collateral and/or points)

Have you ever been denied a license, permit or privelage to operate a motor vehicle?

Yes
No

Please Explain

Has any license, permit or privelage ever been suspended or revoked?

Yes
No

Please Explain

EMPLOYMENT HISTORY

10 Years of Employment History Required if You Were Driving Any Time During the Past 10 Years.

Please visit the link at the bottom of this form to enter additional employment history.

Name *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Position Held *

From *

To *

Reason for Leaving *

Salary *

Explain Any Gaps in Employment

(include month/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations? *

Yes
No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40? *

Yes
No

Second (Most Recent) Employer

Name

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Position Held

From

To

Reason for Leaving

Salary

Explain Any Gaps in Employment

(include month/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Yes
No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

Yes
No

Third (Most Recent) Employer

Name

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Position Held

From

To

Reason for Leaving

Salary

Explain Any Gaps in Employment

(include month/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Yes
No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

Yes
No

EDUCATION

High School

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Name & Location

Details

Course of Study

Years Completed

Did You Graduate?

Yes
No

College

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Name & Location

Details

Course of Study

Years Completed

Did You Graduate?

Yes
No

Other

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Name & Location

Details

Course of Study

Years Completed

Did You Graduate?

Yes
No

OTHER QUALIFICATIONS

Please list any other qualifications that you have and which you believe should be considered.

TO 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.

This certifies that I completed the 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 more information than that required by the Federal Motor Carrier Safety Regulations.

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Signature *

Date *

Name *

First

Last